Value-Based payment is the future for healthcare for the poor.

Text File

There is a solution for Medicaid fraud—innovation

In 2020, Medicaid fraud was estimated to be close to $86.5M. It is a staggering figure burdening taxpayer. And clearly, more needs to be done to remedy a situation where fraud is so pervasively present in a program that cares for the most vulnerable patients.

The FBI lists several main types of fraud: double billing, submitting multiple claims for the same service; phantom billing, billing for a service visit or supplies that the patient never received; unbundling, submitting multiple bills for the same service, or charging more for a service that is usually part of a package; upcoding, billing for a more expensive service than the patient actually received; and over-billing, charging the government for medically unnecessary drugs, procedures, or drugs.

Medicaid patients are particularly vulnerable to physicians' fraudulent practices, as they have no easy access to their medical records. For example, a doctor might falsify or exaggerate a diagnosis to facilitate over-billing. The patient may be subject to unnecessary or unsafe medical procedures. 

They are also vulnerable to individuals asking for their insurance identification number and other personal information to bill for non-rendered services. Or their identity may be stolen, and they would find themselves enrolled in a fake benefit plan. 

To battle rampant Medicaid fraud, a new healthcare delivery model holds great promise: Value-Based Care (VBC). The VBC formula stipulates that doctors get compensated according to the longer-term well-being of their patients. The healthier the patients, the greater the compensation for the doctor. In sum, doctors are encouraged and put in a position to do their very best for the people under their care.

The model, as instituted by the New York Department of Health in 2014, was called Delivery System Incentive Payment Program (DSIRP). It provided for an iron-clad protocol that would make fraudulent practices pretty much impossible. Its success is exemplified by the achievements of SOMOS, a network of 2,500 inner-city physicians caring for some 1 million of New York City's most vulnerable Medicaid patients, mostly Hispanics, African Americans, and Asian Americans. 

To make the VBC model work, doctors must carefully maintain patients' Electronic Health Records (EHR), which would periodically be sent to the Department of Health for assessment. That is when it is determined if the patient population is showing signs of enduring health, which in turn governs the doctor's compensation level. Maintaining the EHRs is a job for both doctors and their staff. Fraudulent records would be readily flagged.

Record-keeping also plays a role in Patient-Centered Medical Homes (PCMH). SOMOS staff works with medical practices to turn them into a one-stop portal where a patient's entire care history is recorded, allowing the doctor to keep track of which services a patient receives, be they medical, behavioral, or social. The social refers to doctors keeping track of patients' social issues that may impact their health, such as substandard housing, unemployment, and poverty. Again, a careful electronic portrait of the patient is maintained, with both doctor and staff doing the record-keeping. Fraudulent entries would quickly be spotted.

Now, doctors prone to committing fraud would be ill at ease being part of VBC, even though such physicians would see their income increase, a factor that prompts their criminal behavior. Ideally, VBC would make honest men and women of them. However, it is hard to picture a less-than-ethical doctor in the SOMOS VBC system, which revolves around a close patient-doctor relationship. That bond is created as physicians earn the patients' trust by getting to really know them, their families, and their circumstances. For much of that intimate detail, SOMOS doctors rely on Community Health Workers as their eyes and ears in the community. Given the stature of SOMOS doctors, it is difficult to imagine fraud-prone physicians, with far less than adequate concern for the well-being of their patients, earning such a position of trust.

Above and beyond traditional Medicaid's vulnerability to fraud and waste, there is a relatively poor record of delivering health care to the most vulnerable. Needy patients, people of color among them, often have a difficult time gaining access to the care they need, given the labyrinthine network of doctors to whom, on paper, they have access. A famous Oregon study (conducted in 2009/2010) found that people with Medicaid coverage showed no significant positive effect on major medical conditions—including hypertension, diabetes, and high cholesterol—compared to those without coverage.

SOMOS saved US taxpayers $330M by reducing by 25 percent both unnecessary visits to the emergency room and unnecessary and costly hospitalization. That is the fruit of Value-Based Care. It is high time for traditional Medicaid to be dismantled and for VBC to be rolled out system-wide. Doctors, patients, and taxpayers stand to benefit greatly.

TEXT FILE

Value-Based Care holds promise to transform healthcare— especially for the underserved

By 2030, the Centers for Medicare and Medicaid Services plans to see all Medicare beneficiaries and most Medicaid beneficiaries enrolled in Value-Based Payment (VBP) or Value-Based Care (VBC) programs. Simply put, VBC links the compensation of healthcare providers to patients’ health outcomes in the longer run. The formula holds doctors more accountable for improving the well-being of the people under their care and provides them with sufficient freedom and incentive to deliver the right care at the right time.

VBC is a remedy for the pitfalls of the traditional fee-for-service system. Fee-for-service means doctors and hospitals are compensated for each service they deliver; they are rewarded for volume—they are paid more if they deliver more services, even if these do not achieve the desired result. VBC changes that dynamic by incentivizing the provision of quality care for the good of the patient—bringing costs down in the process.

VBC also offers a solution for the troubled state of healthcare in the US. The country spends a greater percentage of its GDP on healthcare than other countries. Yet, the US sees the highest incidence of preventable deaths and has the highest infant mortality rate. What’s more, longstanding inequality of access to healthcare leaves people of color and the underserved more vulnerable to illness and disease than the rest of the population. VBC promises to revolutionize healthcare for the most vulnerable.

VBC produced significant savings for taxpayers, as better health keeps people out of ERs and costly hospital beds, and all along, doctors are rewarded for doing a better job. The latter depends to a large degree on the coordination of a patient’s care; that means a primary care physician keeps close track of all the services a patient is getting or needs. This includes medical care as well as behavioral health services. Significantly, doctors are also encouraged and rewarded for being aware of patients’ social needs. Such needs would never be attended to in the fee-for-service model.

Quality of care in the VBC is driven by key dimensions, including efficiency, meaning doctors only use resources that are needed; equity in care stipulates that quality of care does not vary based on race, gender, or income; care is centered on the patient and respects values, preferences, and particular needs; and timeliness means care is given without lengthy delays.

VBC models feature different approaches to doctors’ risks. There is an upside-only risk, with doctors getting more revenue if meet or exceed standards when it comes to quality, cost, or equity. A two-sided risk means doctors also stand to lose revenue if they fail to achieve specific measurements of success. This formula is believed to discourage risk-averse doctors from joining VBC programs.

There are also non-financial rewards for doctors who join VBC programs. The freedom to deliver the right aid at the right time can give providers a sense of purpose and mission. Participation in VBC also enhances a doctor’s reputation.

There is growing interest in VBC models on the part of the commercial healthcare sector. It seems clear the significant growth of the model will require that VBC models become more accessible and offer greater incentives, especially for those providers serving disadvantaged populations. Overall, more research is needed to determine the impact of VBC models on patients, doctors, and the healthcare system at large.

There is a success story in New York City, where SOMOS, a network of 2,500 doctors—most of them primary care providers—is serving some one million of the city’s most needy Medicaid patients. Caring for Hispanics, African Americans, and Asian Americans, the organization has been developing a VBC program since 2014, when it joined New York State’s Delivery System Reform Incentive Payment (DSRIP) program—one of the country’s first such programs.

SOMOS puts its doctors in the optimal position to deliver superior care to their patients. Thanks to the work of Community Health Workers—who visit patients’ homes to remind patients to keep medical appointments—doctors learn of the social circumstances of the patients’ households. These are the Social Determinants of Health. For example, mold in subpar housing may impact physical as well as mental health, while poverty can mean that there are no means to buy fresh and healthy foods.

SOMOS transforms doctors’ practices into Patient-Centered Medical Homes, a gateway to all the care needed for patients, with staff keeping close track of, for example, care given by specialists and its contribution to the patient’s overall health. SOMOS doctors bring another dimension to the job: in many cases, they share a cultural and ethnic background with their patients in whose communities they live and work. Their intimate knowledge of their patients’ health needs and their personal circumstances make doctors into trusted figures and leaders of their communities. This dimension is key to SOMOS’s VBC success. That success translated into savings of $330M through a reduction of 25 percent in the number of ER visits and the number of unnecessary hospitalizations.

There is no doubt that the transformation of US healthcare—especially for the neediest Americans—will require the adoption and embrace of VBC programs. Both doctors and patients are the better for it.