As the industry continues its march toward value-based care, it should do so with a critical eye, says Sachin Jain, M.D., CEO of SCAN Health Plan.
Jain told Fierce Healthcare that value-based care has become akin to religion, with the industry taking it on faith that these models will drive beneficial change. But there are potential pitfalls, and an open dialogue about them is necessary to make sure value-based models evolve to serve patients effectively.
"We've really had an uncritical dialogue about value-based care," Jain said. "I'm just hoping we can simultaneously increase dialogue around some of the potential unintended consequences and how we guard against them."
One of the central challenges of value-based care is managing costs and quality while ensuring patients have a positive experience, Jain wrote in a column for Forbes.
For example, value-based care organizations tend to prioritize palliative care or hospice for patients who have terminal illnesses. While this may be the best solution to reduce unnecessary services—and for patients' comfort—a patient may feel they're not being allowed to fight their illness.
Plus, value-based care models prioritize primary care over specialty care, and they may set up narrow networks to avoid pricey referrals. General practice physicians are empowered to manage conditions or symptoms they might have referred to a specialist under a fee-for-service arrangement. And patients who want to see a specialist for a second opinion could feel as though their healthcare choices are restricted, Jain said.
Utilization management tools like prior authorization also increase this friction. While they do help manage costs and ensure patients are treated by high-quality docs, it can lead to delays for care that worsen patients' experiences.
Jain said he now asks value-based care's loudest advocates what type of coverage they have, an HMO or PPO, after being posed the question himself. Under a PPO, a member can see a specialist without a referral if they choose.
When he responded that he is enrolled in a PPO plan, he was told, "Maybe your belief in the system isn't as high as it should be," he said.
"It's now a question I ask almost anyone who says they're an undying advocate," Jain said.
What can be done to address these downsides in value-based care models? The first step is to talk more openly about them and acknowledge them rather than consider current approaches to be infallible, Jain said. That open conversation will foster development of solutions.
The loudest voices pushing for value-based care should center their "moral compass" as they think about designing these models, he said.
"I think we have to take a balanced approach to anything," he said.