NewYork-Presbyterian physician: Value-based care could leave poor patients behind

In the transition to value-based care, healthcare leaders have failed to consider social disparities among patients in how physicians are supported and paid, a physician writes in The New York Times.

Here are seven insights from the op-ed by Dhruv Khullar, MD, a physician at NewYork-Presbyterian Hospital in New York City:

1. Dr. Khullar discussed the patients he cared for as a resident, who often had several medical problems, little medical care and often did not have a place to stay. "What strained our abilities was not our patients' medical complexity, but their social problems: They were poorer, less educated, more isolated, from rougher neighborhoods," Dr. Khullar writes. "We quickly learned that while it's hard to dose insulin, it's harder still for a patient who speaks no English, has no refrigerator and regularly has his medications stolen."

2. "A growing recognition that social factors influence health outcomes has coincided with a policy push to hold medical providers more accountable for the care they deliver," Dr. Khullar writes. Although these value-based payment models aim to measure quality, outcomes and costs, rewarding or penalizing providers based on their performance, they typically do not adjust for patients' social problems, Dr. Khullar says.

3. The value-based system may be a better way to pay physicians, Dr. Khullar argues, but it could worsen health disparities by discouraging providers to care for vulnerable populations.

"If I'm paid for how many stents I put in or how many patients I see, it doesn't really matter if my patients live on the street or can't read the instructions on a pill bottle," Dr. Khullar writes. "But if I'm paid based on how well their blood pressure is controlled and how frequently they're admitted to the hospital, those things start to matter quite a bit."

4. Dr. Khullar said physicians are justifiably concerned that providing care for socially disadvantaged patients may penalize them for factors they can't control—having a potentially unfair effect on their bottom line. "Under all of Medicare's value-based purchasing programs, for example, providers who treat more socially complex patients suffer higher penalties," Dr. Khullar writes. "And patients with more social risk factors have worse outcomes regardless of who they see."

5. "Doctors who care for disadvantaged populations need more resources to produce comparable health outcomes, but they're less likely to have them," Dr. Khullar writes. The patients these physicians care for are frequently uninsured or on Medicaid. Additionally, these physicians may have more difficulty ensuring their patients have access to necessary medical services, such as subspecialty care, diagnostic imaging and nonemergency hospital admission, Dr. Khullar says.

6. Dr. Khullar suggests a having "public report cards" for physicians and hospitals based on the socioeconomic characteristics of patients they care for, or adjusting bonus payments for those that take on a greater number of disadvantaged patients.

"But whatever model we might end up adopting, selecting the right types of measures will be important," Dr. Khullar writes. "It probably doesn't make sense to adjust for social risk when assessing whether a patient got aspirin for a heart attack or the right antibiotics for an infection, but it does when measuring how well a patient's diabetes or blood pressure is controlled over time." Dr. Khullar also argues for a system where clinicians are rewarded for improvements in care and are compared to their previous performance or similar providers as opposed to being rewarded for meeting absolute thresholds.

7. "Paying doctors to do better — instead of to do more — is essential for a higher-value health system. But if not done carefully, we risk leaving some patients behind," Dr. Khullar writes. "Better care for those who've been dealt a bad hand will mean making sure doctors aren't playing against a stacked deck."

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