Lancaster Physician Spring 2017 - 35

SPRING 2017

Paying for Value?

As stated previously, value is defined as
outcomes divided by cost. So all we have to
do is figure out what the outcomes and costs
are, and we've got it figured out, right? One
would think that cost should be the simple
part. If only that were true! One can't use
the prices hospitals and physicians charge,
as they aren't similar to what those entities
are paid. One could use what Medicare
pays, but Medicare pays different prices
for the same procedure based on a number
of factors, and the approved diagnoses for
each procedure differ significantly by region.
Furthermore, the process where Medicare
decides what it will pay for each procedure
is a highly politicized process akin to a large
group of sharks fighting each other as they
devour an injured whale. In a rational world,
the cost to Medicare would be based on the
actual costs of delivering the procedure,
with a predetermined profit margin that is
uniform across specialties and doesn't favor
one group over another. But it is difficult
to see a way to achieve that goal with the
system as it now exists.
Defining the other half of our equation,
outcomes, is an even more precarious process
because the goal of creating a fair system
seems even more remote. From quantitative
subjective outcomes (such as patient satisfaction scores) to objective outcomes that rely
on patient adherence (like hemoglobin A1c
levels), hospitals and physicians are forced
to focus on the processes that they control
and then hope for the best. Undoubtedly,
there will be ways to game the new system,
just as the current system has ways to game
it. Some physicians will embrace this, but
most will not, as physicians tend to focus on
trying to do the right thing by the patient.
In a rational world, outcomes would not be
used to reward or penalize individual physicians but would be used to value procedures.
For example, if one procedure has a global
satisfaction rate of 25 percent and another
has a global satisfaction rate of 90 percent,
then giving a higher relative value to the
appreciated procedure will reflect the collective will of the patients. If one drug extends
survival by one month, but another drug
extends survival by six months in the real
world, providing differing reimbursement

would be logical. Again, it is difficult to see
a way to achieve a fair, transparent system.
This essay is not going to solve the problems of health care reform. We must all
remain engaged to help influence the system
as it evolves. Irregardless, we live in this new
world. There are measures that demonstrate
our quality and outcomes, as defined by
the MACRA legislation and associated
regulation, and there is data that needs to
be collected for the federal government.
Employers are engaged in this to differing
extents, but PAMED has wisely decided to
work with all physicians, providing management services and organizing physicians into
a clinical integrated network. Just as PAMED
created a professional liability insurance
company (PMSLIC) to help members and
nonmembers throughout the state during
the depths of the malpractice crisis, PAMED
is here to help prevent a crisis in the large
segment of Pennsylvania physicians that are
either in private practice or work for small to
mid-sized physician groups. I encourage all of
you to learn more about PAMED's important practice options initiation.* PAMED is
providing value to Pennsylvania physicians
by helping them demonstrate their value.
This value analysis can be applied further
to other aspects of PAMED and the county
societies as well. The cost is the membership
dues. The outcomes are both tangible and
intangible. One of the tangible outcomes
for county membership is receiving this
magazine, which can be a mouthpiece for
any member to communicate with our
community. Additionally, one can join us
in networking events, engaging our elected
officials, or helping to change PAMED policy in the House of Delegates. PAMED has
numerous tangible member benefits from
practice support, to continuing education,
to timely information on statewide political
issues and how you can be involved. The
intangibles are just as important. Nurse
practitioners would have been granted the
same license to practice medicine as physicians years ago if it weren't for PAMED
advocacy. How much more time-intrusive
would the opioid database be if PAMED
wouldn't have worked with legislators to

LANCASTER

35

PHYSICIAN

find a balance between the need to decrease
inappropriate prescriptions and the need
to eliminate needless inquiries that reduce
the amount of time physicians spend with
patients even more? At the end of the day, if
PAMED and the counties provide enough
positive outcomes for each dollar of membership dues spent, they will both thrive.
But if not, it will be up to the collective
membership to adapt their priorities and
cost structure. There is an obvious need for
a medical society. The question isn't whether
or not it will survive; the question is whether
or not it will be relevant, or an afterthought.
We as physicians are committed to building a better future by providing as much
value as possible, for our patients, and for
our fellow PAMED members. Thanks for
staying involved!
Dr. Mackley is a Radiation Oncologist at
the Penn State Cancer Institute and Associate
Professor in the Penn State College of Medicine.
As the 5th District Trustee on the PAMED
Board of Trustees, he represents physicians of
this county.

REFERENCES
*https://www.pamedsoc.org/tools-youcan-use/ practice-options-initiative


https://www.pamedsoc.org/tools-you-can-use/ practice-options-initiative https://www.pamedsoc.org/tools-you-can-use/ practice-options-initiative

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