The majority of health care in the U.S.—and the majority of hospital medicine practice models—is delivered on a fee-for-service basis, but is that the best construct through which to administer treatments, therapies, and bedside manner to hospitalized patients?
Well, that’s the central question of SHM’s Value-Based Care Special Interest Group (SIG).
Dr. Ramanathan
“What we hope to do is generate interest within the groups who are working within the value-based sphere,” said SIG vice chair Vivek Ramanathan MD, MBA, CPE, FHM. “Meaning right care, right time, right place. The financial goal is being aligned with that. So, that’s what we want, and that’s where many hospital systems are heading, too. That’s why we’re generating such a lot of interest within SHM.”
The sales pitch for that might seem like a massive headwind to some, but Dr. Ramanathan, a regional medical director in Southern New Jersey for Sound Physicians, sees it differently.
“Most doctors want to do the right thing, right?” he said. “What we’re facing is a financial misalignment, as well as a patient-expectation misalignment. If we are aligned with financial incentives, not making that the number-one thing, but it certainly helps, I think you can all move toward what we eventually want to do, which is drop the entire cost of health care.”
And while that can seem like “a big, hairy, audacious goal,” Dr. Ramanathan recently experienced it firsthand when his mother-in-law called him, borderline hysterical. She had severe abdominal pain and rectal bleeding. She called her primary care physician—as she should have—and as that physician was out of the office, the call went to a physician assistant (PA) who after a brief conversation told her to go to the emergency department (ED) for a CT scan and other testing. Dr. Ramanathan instead decided to visit her and after a physical exam, decided that her presentation of “a soft belly” could be much less severe than anything necessitating a trip to the ER.
“I said, ‘Look this could be a bout of diverticulitis, you could just be constipated,’” he said. “I checked her vitals and gave her some MiraLAX. Seven days later we go see [a gastroenterologist], and they say, ‘Look, it is probably some diverticulitis, colitis. You did the right thing. Let’s get a colonoscopy,’ which is really the test that you need.”
Dr. Ramanathan says the issue for physicians isn’t that they want to send folks to specialists and EDs for things that could be handled other ways—it’s the “elephant in the room….the litigation component.”
“The PA who picked up the phone for my mother-in-law doesn’t know my mother-in-law,” he said. “She’s thinking that, if this is something catastrophic, I don’t want to tell her to stay at home. That’s my license. We immediately jump to the quickest, maybe the safest, safety net.”
To Dr. Ramanathan, the SIG is a home for physicians looking for better care delivery systems.
“We all have different perspectives and different masters, as it were,” he said. “But the one master we should all be paying attention mostly to is the patient, right? So, people and processes, we’ve got really great minds and it’s sharing our processes, which has been super fun. How did you get there? How did you get the C-suite to align with moving away from quantity and going towards quality? How did you get your docs to turn patients around in the emergency department? How did you get them to reduce their inpatient testing?”
Like other SIGs that deal with overbroad topics, one of the hurdles for value-based care is that the topic seems so big as to be unmanageable.
“The fact that it’s so wide is kind of why we have struggled a little bit, trying to get it ramped up,” Dr. Ramanathan said. “And the way you do it is the journey of the patient. From the outpatient world to the emergency department to the hospital, where we are, as hospitalists, and then connecting it back out to the outpatient world. Whether that’s a post-acute space, home health, or telemedicine, all of those things need to be incorporated.”
Dr. Ramanathan does see progress. Decades ago, health maintenance organizations were an iteration that tried to address value-based care. But those ended up, in many instances, being about the rationing of care.
“What we want is that phrase: right time, right place, right care,” he said. “Empowering doctors to do the right thing, but incentivizing them to do the right thing, too. And so, I think we’ve been doing it forever. But where the inflection point is when you see the health care costs in the U.S. You’ve seen the outcomes, so something has to be done differently.”
Richard Quinn is a freelance writer in New Jersey.