Abigail Hardin 
Abigail Hardin, Ph.D., is an assistant professor in the department of psychiatry and behavioral sciences at Rush University in Chicago and a licensed rehabilitation psychologist.
Vaccinated Americans are angry for a good reason: We have access to a safe and inexpensive source of prevention, and yet despite the availability of vaccines, 25% of Americans will refuse the shots, and many will suffer or die. The anger is familiar for healthcare workers, who regularly see patients suffer or die due to lack of access to preventive care. Healthcare is struggling on this front, but one adjustment to the system could help.
Currently, physicians and other providers receive payments based on a system of relative value units (RVUs), which determine how much insurance, including Medicare and Medicaid, pays for a given type of service. The RVU system was notably flawed from the start and is policed only by those who have significant skin in the game to the exclusion all others: physicians. A small group of physicians called the Relative Value Scale Update Committee (RUC) reviews healthcare services and recommends changes for services they deem over or undervalued to CMS. The agency makes the final determination about payments for services, but evidence shows they overwhelmingly accept the RUC’s recommendations. Physicians determining how much money their own services cost represents a clear conflict of interest.
The RVUs assigned to any given service are based on three core components: the effort that goes into the service (determined by the physicians who provide the services); equipment and space costs; and the costs to cover professional liability insurance. Notably absent is any component that weighs whether the service actually provides good healthcare. In other words, the financial foundation of the healthcare system has no method for ensuring money is spent providing high-quality care that prevents health problems. One doesn’t have to be an economist to understand how profoundly backwards this is.
Since the 1970s, economists, managed-care organizations and researchers have been trying to solve this problem. Approaches like value-based care and proposals like Medicare for All offer potential solutions, but the complexities of the system and differing opinions about how much the government should be involved in private healthcare has slowed progress. Most healthcare remains fee-for-service.
But the reality is that the RVU system could be replaced without involving big government and without reformulating the entire care system. If an adjusted value system were in place, it could address some of the major issues plaguing healthcare, like the fact that it is much more remunerative to amputate a leg due to complications from diabetes than it is to treat the diabetes in the first place.
An adjusted value unit system would still include key components of the current RVU system like costs, effort, and liability. However, it would also incorporate a weighted prevention index, which would help incentivize hospitals and clinics to provide services that are most preventive and cost-saving down the line. Doing so would have an immediate effect. Physicians, hospitals, clinics and other practitioners could be incentivized to provide the type of care that would keep people healthy. The change could save lives and money.
To be sure, hospitals would see a decrease in payments for currently highly remunerative procedures. And indeed, eventually this could result in decreased demand for many high-cost procedures. An adjusted value unit system would instead see an increase in payments for those that were most preventive, like visits to a primary-care clinician for diabetes management, regular health check-ups, or a behavior specialist to assist with switching to a diabetic diet. This seems like a much better use of our healthcare dollars.
There are a few barriers to implementing an adjusted value unit system. The first is developing prevention indices for each class of procedures, a task that would be difficult but possible given the tremendous existing research on healthcare outcomes and economic impacts of disease.
The second major barrier would be largely political. Wresting control of the healthcare financial system from those who are currently empowered by it would be difficult, but not impossible. Indeed, the American Medical Association contends in its documentation about the RUC that the RVU system “must remain in the hands of the medical profession” and, by extension, insulated from input from nurses, social workers, psychologists and others who may provide lower-cost and effective preventive services.
The good news is that the current RVU system is simply a recommendation to the government from a group of physicians about how to spend the country’s annual healthcare budget. It’s time for healthcare professionals to band together for a system that incentivizes preventive care and long-term savings by presenting a new recommendation: an adjusted value system.
Source link : https://www.modernhealthcare.com/opinion-editorial/healthcare-payment-should-be-retooled-focus-prevention
