In Focus: Physician-Led Efforts to Promote Value

Originally published in The Commonwealth Fund

Physicians are proposing new ways of delivering and paying for care that take aim at a key shortcoming of the nation’s fee-for-service system: lack of payment for some high-value services. Their condition-specific models encourage adherence to evidence-based guidelines and reductions in avoidable hospitalizations and testing that has little benefit. Finding payer support for these models has proven challenging for some despite evidence of cost savings or improved health outcomes.

With the share of the nation’s gross domestic product devoted to health approaching 20 percent and a tsunami of aging baby boomers closing in, it’s clear the United States needs to find creative ways to curtail health care spending. Unfortunately, many such efforts led by payers and policymakers — including pay-for-performance, accountable care, and bundled payment programs — have produced only modest savings.

Some physicians have taken up the challenge and put forth their own ideas to achieve greater value for health care dollars. Many leverage grant funding from the Center for Medicare and Medicaid Innovation (CMMI) and elsewhere to test their ideas. Some proposals come in response to Medicare’s call for ideas on how to move away from fee-for-service payment and promote high-value care. Their new care models take aim at common and costly conditions such as cancer, cardiovascular disease, and musculoskeletal problems and seek to achieve savings by encouraging greater adherence to evidence-based guidelines, engaging patients in decision making, and avoiding complications that can lead to unnecessary care. Their condition-specific approaches could benefit patients who have frequent interactions with health care providers and may be vulnerable to complications from treatment.

Since December 2016, physicians — represented by physician groups, specialty medical societies, and others — have submitted 25 proposals to the Physician-Focused Payment Model Technical Advisory Committee (PTAC), which was created under the Medicare Access and CHIP Reauthorization Act of 2015 and tasked with evaluating physicians’ ideas for new payment models.

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