The Future of Value-Based Care Must Prioritize Equitable Healthcare Access for All Patients

For AAOS Now, Editor-in-Chief Robert M. Orfaly, MD, MBA, FAAOS, sat down with Adolph J. (Chick) Yates Jr, MD, FAAOS, associate professor and vice chair of quality management in the Department of Orthopaedic Surgery at UPMC in Pittsburgh, Pennsylvania. Dr. Yates is an expert in the world of value-based care and healthcare-delivery systems. He spoke with Dr. Orfaly about his views of the evolution of value-based care and the relationship among healthcare, government, and regulators.

Dr. Orfaly: What do you see as the necessary evolution of value-based systems, particularly with regard to the payment for these systems?
Dr. Yates: From 30,000 feet up, the bottom line is that there is going to have to be, at some point, reform of entitlements. It is going to be a very tough political battle. At some point, Medicare, as one of those entitlements, has to be reconstituted and made secure. Up until now, it has been something that has been squeezed and massaged. With the sustainable growth rate and all the different cuts that come in automatically, it is just not working. Society at large needs to realize that the United States provides the absolute best medical care in the world. People come here from all over the world [to receive care]. At the same time, though, to provide that in a fair way for all patients, we are going to have to look at how do we fund that, how do we make that fair, perhaps on an income basis.

In physician payment, we often talk about the “one pie” that all physicians have to take from. What are your thoughts on how that pie gets distributed and what the effects are of this concept?
The one-pie concept grew out of the institution of relative value units and the resulting evaluation and management codes and CPT codes that generate those relative value units. It has always been an underlying assumption that the number of such units would be “one pie,” if you will, and that all the different specialty and non-specialty physicians would decide between themselves how it was going to be carved up. The fact of the matter is that the pie is too small. It is too small to reward innovation and growth and technology that has evolved and the number of specialists that has grown since I started my career. The way the pie has been divided, historically, has been through the [Relative Value Scale Update Committee (RUC)] and through decision making based on time spent taking care of patients, and that it is done on a survey basis, and that, quite frankly, has not been enough.

The other way that it has been treated, and one of the ways that value-based care has been instituted by Medicare and [the Centers for Medicare & Medicaid Services], is to put physicians in competition with each other such that there are winners and losers in terms of higher reimbursement versus lower reimbursement. It has been applied to the hospitals and it has now, since 2015, been a major part of the [Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)] or the process that assigns [Merit-Based Incentive Payment System (MIPS)] scores for different surgeons. Within MACRA, somebody could be 9 percent up or 9 percent down, but it is a zero sum. That is the critical thing. As a zero sum, it means that we are competing not just within that pie, within what we think of relative value, we are now competing against each other on quality metrics. Those quality metrics and the performance measures that are used to capture them, quite frankly, have not been well risk-adjusted. They are not accepted as risk-adjusted. Some of the risk adjustment, for better or worse, should or should not be used. [This] includes socioeconomic risk adjustment and whether or not there is physical evidence for it. There is a perception by surgeons that certain patients with medical comorbidities are going to cost more and have more complications.

It is a real imperative for the sake of the health of the whole population, but in particular for equity, that we really address these issues.
It is equal access. It is equal and fair access. It is making sure no one is left behind. If a surgeon takes on the more difficult patient, if the surgeon takes on the patient with higher risk, it ought to be something that is an exemption. It should be … recognized as a different category of risk. There is precedent within the government, having passed the 21st Century Cures Act; they actually imposed the requirement for the Readmissions Reduction Program to start stratifying hospitals by the number of patients with dual eligibility, meaning that they are poor enough to get Medicaid supplement for their Medicare. And [they established] five different strata dividing patients and the hospitals so that hospitals were competing against like hospitals in terms of—I do not want to say burden, but the challenge of more impoverished neighborhoods and neighborhoods where it is just hard to take care of people. I have debated this with some people in the past, who say it is not really proven that there is a difference in socioeconomic risk. I will say, the patient that lives on the fifth floor of the tenement in Little Italy in the Bronx, whose one cousin has the truck once a week on a Saturday, is going to be a more difficult patient in terms of transportation, return to the office, getting to and from the emergency room. It is going to be a very different social economic milieu. It is an entirely different social topology in that environment than say in suburban Palo Alto, where a car is a birthright. If you look at somebody and say something about the second floor, they look at you like you are crazy.

It gets down to the physician’s role as a coordinator of care and how certain patients require much more care coordination. It goes beyond the time in the OR, into the entire episode of care and how much effort it takes to ensure a good result for every patient.
We have had to work much harder in the preoperative period preoptimizing patients. Unfortunately, when you present to the RUC, they consider the preoperative period for a global period was one day. It would not accept the argument that we have been working really hard and the reason that the length of stay dropped and the quality improved was the work that went into the preoptimization and the preoperative planning. When sitting in front of the RUC, I made the comment that 20 years ago, I did not have the conversation with the patient as to which floor their bathroom was on, but now I do. I have to know what the challenges are for getting them home, as opposed to them being trapped in a skilled nursing facility.

Given the current environment in government and in society, what do you think is the most likely path forward to provide equitable and high-quality care and to move forward as a profession?
I am very happy and proud to say that orthopaedics, more than any other specialty, is probably engaged with [the Centers for Medicare & Medicaid Services] and the [Center for Medicare and Medicaid Innovation (CMMI)] trying to make value-based care and bundles and the like work. We have had the greatest experience, and we have also had the greatest amount of deserved trust from those agencies in terms of what we bring them. We have developed a web of interconnections with the regulatory morass that for a lot of other specialties and a lot of our society does not exist. But for Medicare and CMMI, we have made a lot of regulatory inroads in terms of getting our message across and what needs to change. They have been very open about inviting us in to be part of listening sessions and to be part of planning sessions for the next attempt at the next generation of value-based care.

Likewise, we have enough legislatures, legislators, and members of the Doctors Caucus … that know that we have developed a special expertise in terms of working on this. We need to be hopeful. We need to realize that the first time around over the last decade has been a little rough. I am hoping that for the future, [physicians receive a] bigger pie, smoother processes, [and] recognition that competition between doctors may cause loss of access, [and for the government to] think in terms of historical improvements, in terms of benchmarking, in terms of letting every doctor show improvement on their own and rewarding them for that improvement. And reward the people that take care of some of the more challenging patients in a way that has not been done before. I’m hoping that that is what happens over the next decade.

Robert M. Orfaly, MD, MBA, FAAOS, is a professor in the Department of Orthopaedics and Rehabilitation at Oregon Health and Science University. He is also the editor-in-chief of AAOS Now and chair of the AAOS Now Editorial Board.