The Invention of the Minivan
Imagine, if you will, a country where everyone moves from place to place in single person combustion engine vehicles. A country where all the laws, expectations, and infrastructure is built to support only single person vehicles. In this world of singular travel, the population realizes that it is inefficient and that all of these single person vehicles are burdensome not only in terms of space but of pollution and traffic. In order to change their ways and improve the acceptable methods of travel they begin to make laws requiring change and the creation of… the minivan.
This new multi-person vehicle is more efficient, produces less pollution per person, and is superior to the single person vehicles in almost every way. This leap in progress does not come without its drawbacks. For example, many roads have not been created for a vehicle as wide as a minivan and often cause traffic jams where they once never existed. Revenue from tolls suddenly begins to drop. The same amount of people are passing the tollbooth but the number of vehicles has reduced as the person per vehicle ratio has risen. This hypothetical place becomes polarized over the issue and people are suddenly either a SP (single-person) supporter or a MV (minivan) activist. Political turmoil abounds as debate and discussion stifle change and the issue only becomes more perplexing when someone invents the 4-door sedan.
I imagine that you have only continued to read so far because you are curious what my point is… Well you are in luck. I will likely tell you what I am up to in the next few sentences. Or maybe not. In either case here is a picture of my cat Finnegan as a reward for getting this far.
The hypothetical circumstances I described above are an allegory for the healthcare industry in the U.S. In case you hadn’t guessed it yet, the “multi-person vehicle” is really this newfangled idea I’ve been blabbering on about for the last few months. My point was to illustrate an instance where a complex system was built to function one specific way. This situation can hamper change, and sometimes progress, because the underlying infrastructure is not equipped to adapt. Not necessarily because someone wants it to stay the same but simply because the system has never had to change.
So, if you are still with me here is the whole point (I told you it was coming). Value Based Healthcare is such a profound change from the current way of doing things that the infrastructure and legal framework for healthcare in the U.S. is not completely equipped to handle the change. In fact, there are a few legal establishments that are barriers to adopting a value-based payment model. Anti-fraud laws that exist today were designed for a fee-for-service model in a world where doctors often worked for themselves instead of for larger healthcare groups. The Stark Law and the Anti-Kickback law have been specifically indicated by the American Hospital Association as major blockers to the adoption of the value-based initiatives put forth by the MACRA legislation. These laws inhibit hospitals from being able to initiate collaborative and coordinated care for patients without the possibility of legal ramifications. The MACRA legislation even states that the Department of Health and Human Services must make legal exceptions and changes in order to allow for easier pathways to success for new and innovative payment models.
Legal barriers are only one part of the complex landscape that has to be tiptoed through in order for coordinated care partnerships to flourish. The connectivity of systems, equivalent health record formats, as well as organized and consistent billing for each episode of care from both institutional and outpatient providers are all necessary components for a complete VBH system. While it is easy to put these down in words, it’s not so easy to overcome such hurdles. The reason? The minivan was just invented and not all fuel stations, mechanics or dealers are equipped to handle it.
The takeaway here? If we, as a population, want to make sure that concepts like VBH survive and take hold, we must do what we can to embrace the change. If positive sentiment from patients and legal backing from the government can support each other, more and more providers and payers will make the investment in change. I would say that VBH is already well on its way but even the best-laid plans can fall prey to unstable circumstances. I don’t think that will happen but in my experience it’s always better to be prepared and keep a watchful eye.