🔒Doctors push value-based contracts, education

Hospitals and insurers face plenty of uncertainty as they try to discern how President Donald Trump's promised repeal of Obamacare and other potential health policy changes will impact them.

Depending on how things play out, federally encouraged (and even mandated) experiments with alternative-payment models like accountable-care organizations and bundling could be scuttled.

That's created much anxiety in the healthcare industry, particularly among doctors who insist that such “value-based” models — not all of which are yet proven to save money or improve health outcomes — are the right approach to steer the healthcare industry away from a long dominant fee-for-service model, which tempts medical providers to order unneeded tests and services.

“Value-based health care will go forward in some way, shape or form, and the reason is that it makes a lot of sense,” Dr. Richard Iorio, a New York University orthopedic surgeon, said recently in a Hartford stopver. “There are better outcomes for patients and it saves money in general.”

Iorio was recently speaking at St. Francis Hospital and Medical Center as part of a day-long seminar that was essentially a crash course on healthcare payment models. The audience included approximately 20 physician-residents from St. Francis and UConn and several Quinnipiac University medical students.

Other physician-residents watched doctor presentations via video feed from a medical school in Texas and an orthopedic institute in California.

Iorio came at the behest of Dr. Steven Schutzer, an orthopedic surgeon and director of St. Francis' Connecticut Joint Replacement Institute.

Schutzer said he agrees that value-based models are here to stay, regardless of politics.

“I really don't think we're going to turn around and embrace fee-for-service as a dominant payment methodology,” said Schutzer, adding that alternative-payment structures can only truly succeed if more doctors become experts in how they work.

“At the end of the day, it's not that complicated conceptually,” he said. “Operationally, it's incredibly complicated.”

Schutzer would know. In 2012, he spearheaded St. Francis' first foray into a bundled-payment contract, under which ConnectiCare pays a set price for a set of services related to hip and knee replacement surgeries. The contract has since evolved to include post-acute services and a “warranty” for the three months after a surgery patient leaves the hospital.

Bundled arrangements remain a small piece of St. Francis' overall revenue, and are still uncommon at most Connecticut hospitals.

One challenge, Schutzer said, is that newly minted doctors often don't know enough about value-based models, which can vary. Schutzer said the topic should be a larger part of the curriculum in residency programs and even medical schools.

But it's not an easy sell. Schutzer said he invited residents from Massachusetts, Rhode Island and New York to the Hartford event, which took place in December, but was told they were too busy or unable to attend. The 20 residents that did show up were hard won.

“I thought we would get 400 residents,” Schutzer said. “We really had to beat the bushes to get them here.”

For the organizer of an event dedicated to exploring the measurement and application of healthcare value, Schutzer couldn't help but wonder if the many hours he and his colleagues spent organizing it were worth the effort.

Like most things, it depends on how you measure it, he concluded.

“I guess at the highest level we want to inspire a new generation of leaders that can change the mindset of others,” he said. “If we have 20 kids here and maybe 50 online, and if half a dozen step up to become leaders, we've accomplished our goal.”

Though an eight hour deep dive into value-based contracting may not be enough to turn residents into healthcare-business experts, it at least gets them thinking about it, he said.

That knowledge can also be useful to residents in deciding where to work when they enter into practice, and it may yield more valuable offers from prospective employers, said Dr. Cynthia “Daisy” Smith, vice president of clinical programs for the American College of Physicians.

“They need to understand the environment in which they'll be practicing,” Smith said. “High-value care is a team sport and participating in these alternative-payment models is a team sport.”

Curriculum review

New financial models may provide the best realistic shot at stemming rising healthcare costs, but Schutzer and his fellow alternative-payment proselytizers contend it will only happen if doctors increase their collective knowledge about how they work.

They argue that such education should begin as early as medical school, though there is debate about that.

From pre-med through residency, it takes more than a decade to train a new doctor. Given that time span, and the fact that payment models evolve over time, educators grapple with placing more focus on payment models, given their core mission to teach the knowledge and skills needed to provide medical care.

“That's an issue that every medical school wrestles with on a regular basis because everything is changing,” said Dr. Bruce Koeppen, dean of Quinnipiac University's medical school.

Koeppen recalled what one of his own teachers told him in medical school in the 1970s: “There's good and bad news. Half of what you will learn in medical school won't be correct in 10 years. The bad news is I can't tell you which half.”

Payment models aren't part of Quinnipiac's current curriculum, but it's possible they will be following an ongoing review, he said.

At UConn Health, there isn't an official curriculum component for residents involving payment models, though faculty has more recently begun to include it among the topics discussed during weekly academic sessions, according to Dr. Vincent Williams, who spoke at Schutzer's seminar.

“We're starting to introduce that more and more,” Williams said, adding that he agrees young doctors with that knowledge could be more attractive to physician groups.

Several years ago, concerned about rising healthcare costs, the American College of Physicians developed a curriculum for residency programs that includes alternative models, which has been updated several times since.

Smith, who worked on the project, said hospitals are free to use some or all of the framework, which has been downloaded more than 45,000 times.

“I think the impetus was we felt we really needed to do something,” Smith said. “This is clearly an identified gap and I do agree the sooner you close it, the better.”