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Value Based Compensation Models - how do they really work?

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  • Value Based Compensation Models - how do they really work?

    Anyone else have employers talking about switching over from RVU-based models to "value-based" models?

    Big admin has warned us this is coming and has the talking points down about why they want to impose changes, but only offers hand waving when specific proposals are requested. Our toadying department representative even told us we could google specific models when we asked him about it.

    It feels like just another pretext to pay us less, and to transfer risk of noncompliant patients from the system to the physician. Am I just being cynical, or is it really not that bad?

    Looking for perspective from people who have already transitioned to these models.

  • #2

    It feels like just another pretext to pay us less
    Click to expand...

    This is probably true (or maybe we're both cynical), but if it was revenue-neutral and based on providing evidence-based therapies (e.g., statins post MI, anti-coagulants for appropriately selected AFib patients, etc.), then I'd welcome it.

    We have no control over patient compliance with recommended therapies and lifestyle changes, so it would be inappropriate to link our compensation to that. Of course, that wouldn't prevent insurers from implementing that change.
    Erstwhile Dance Theatre of Dayton performer cum bellhop. Carried (many) bags for a lovely and gracious 59 yo Cyd Charisse. (RIP) Hosted epic company parties after Friday night rehearsals.


    • #3
      We are starting this next year. I’m skeptical. I was about to cut down to part time but it made me cautious to see how much my salary may decline. Ours have a model that even if you only produce 85% of what you made last year, you’ll get the same salary. Then you get bonuses if you meet the “values” they set. However, if I exceeded >85% of what I made last year, the dollar amount is small = $26/rvu. And I don’t get this unless I fulfill all the values they set ?‍♀️


      • #4
        My employer has also mentioned the same switch from RVU to value based. Like you, I'm skeptical it'll pan out well for those of us doing well with RVUs. Also interested to hear from anyone else who's made the switch. DrV - I've have the same thoughts about waiting to decrease my FTEs until I see the numbers.


        • #5
          I am currently RVU based. With RVU's, we just submit the code and the billing software calculates it. How is admin exactly going to track all these other metrics? It requires enormous resources to be scanning EMR's all day, keeping tabs on lab work, physician prescribing practices, follow up patterns, and readmission rates. And how much does investing that manpower in more administrative bloat really improve clinical outcomes? No matter how many bean counters we have auditing the charts, the patient who doesn't fill his meds and stops at McDonald's and the ABC store on the way home probably won't have a happy ending.

          The frustrating thing is that my system refuses to define what good outcomes even are. They use nebulous terms and phrases that make me think they're intended to be subjective (punitive).


          • #6
            The admin hand-waving, as I understand it, is because this change is being driven by CMS as part of ACA legislation. They know it's coming, but without CMS telling them, they can't tell you either.

            As you point out, we as doctors can do all the "right" things (tell our patients to stop smoking, exercise, etc etc) but if they want to be at McDonald's after the appointment we can't stop them. This incentivizes picking "good" patients who will have access to medication and a desire to take it, already don't smoke, and are not at the mercy of inconsistent health coverage.

            Expect patient satisfaction to be part of the "value" measurement. This is also from CMS despite its insanity (you can think I'm a swell guy even though I missed the obvious melanoma on your nose because I refilled your Xanax).

            My own employee contract as a hospital-based physician has the"value" part structured as a clawback, ie if I fail (or the group as a whole fails) to meet specific benchmarks we lose X% of our salary. This obviously stinks but so far the benchmarks have all been reasonably clearable and I'm not aware that anyone in the group has lost money from this.

            If you think you will get paid more under any of these arrangements than you do now, you should disabuse yourself of that notion. The money to pay the salary of the person in charge of collecting all this data isn't coming out of the administrators' pockets.


            • #7
              This was a portion of the compensation model I alluded to in the other thread (the one about feeling unaccomplished). Somewhere between 10-15% of our overall compensation would be based on “value driven care”, which the administration could not/would not define for us. But when questioned, they did say that if the hospital system didn’t meet its goals (financial and otherwise) that we would not be awarded that portion of our compensation.

              Seems pretty screwy to base a fairly large portion of our pay on things over which we have no control.


              • #8
                are you talking how does MACRA work? payments start in 2019. (and penalties).


                • #9
                  I agree the value based care is concerning secondary to all of the uncontrollables listed above. Also, what will happen to volume if we shift from an RVU system? I don’t enjoy adding patients to a double booked schedule, staying late, missing out on family time, etc. But, at least in the current system I’m compensated for the extra hours or extra surgery. Essentially paid for your work which is reasonable. If we progress to a value based system that doesn’t pay for the amount of work done why would anyone see 30+ a day, add on patients, do long surgery days. Don’t get me wrong, I care about my patients and enjoy working hard but not sure I’d continue 80hrs a week and continually adding on patients for a decrease in compensation.


                  • #10
                    This is an article of faith with large health care company administrators.  Like other forms of ideology, it is difficult to discuss in an open and honest way.  In my experience, when you drill down and try to ask questions like fairness among specialties, providing the wrong incentives, "teaching to the test" rather than providing appropriate care, etc., you get a lot of mumbo jumbo.  The fact is there isn't a good model out there, but here we go.


                    • #11
                      Cherry picking patients may occur, unintended consequence.  Will only see patients with no systemic diseases or complex needs.   Will only do physical exams on healthy young patients then add them to my patient list and thus patient patient compliance dramatically improves, and thus obviously increased quality and value from the provider.


                      What happens when non physicians drive the metrics for patient care?   Unintended consequences and next thing you know multiple unintended consequences and adjustments you actually lose site of the initial intent.   For example patient satisfaction,  some patients quickly learned the art of subtle threats to ER providers, that if I leave with no pain control plan to bridge me until I eventually see a pain doctor that your yelp score may go down and thus your administration would not look to kindly on this result.......   opioids RX........