Over the past decade, the Centers for Medicare and Medicaid Services (CMS) has shifted its payment structures away from volume-based care and toward value-based care. This means that payers and providers, who had been reimbursed based on how many patients were treated and for what diagnoses, have also shifted the management of patients’ health from treating single episodes of illness or injury to evaluating the non-clinical social factors that contributed to the patient needing care in the first place.
To discuss some of the challenges that providers face with this switch to value-based care, I spoke with Thao Tran, M.D., MPH, a physiatrist and the Chief Medical Officer and Chief Quality Officer for Provider Network Solutions in Miami, whose background with and passion for innovative care models can help payers and providers understand the models’ value. Dr. Tran’s insight captures the frustration of providers and paves the way for use of Spatially Health’s ability to analyze data generated by biological, behavioral, and socioeconomic factors, including the physical space an individual inhabits, and address the non-clinical factors that drive healthcare needs.
HM: You have such a diverse background, which started in engineering before pursuing a medical degree and practicing in the specialty of Physical Medicine and Rehabilitation. What has this unique path taught you along the way?
TT: I began pursuing a career in chemistry and chemical engineering, which showed me the value of research in positions I held at Shell Oil and at Environmental Labs. I developed some cool stuff before going to medical school. While I started out at medical school in surgery, I turned to Physical Medicine and Rehabilitation and began practicing in that specialty. That’s where I learned about how clinical practice can be impacted by financial models. I saw it in the early 90s, when financial models in post-acute care switched from fee-for-service to the Prospective Payment Model. Instead of providers receiving reimbursement based on how and where they treated their patients, hospitals would get a lump sum of money for post-acute care, and they had to learn how to deliver the best care within a specified timeframe.
HM: That was your introduction to a form of management to overall care?
TT: Yes, that was how CMS handled payment for post-acute care. When I was at Baylor College of Medicine as a faculty member, I had to learn how to design post-acute care within that payment structure and come up with new ways of doing things. Then, at Houston Medical Center – a top tertiary care center in the U.S. – I learned a lot about delivery care models and integrated those that were not existent at that time. After 12 years, I brought some of those new models to Miami, where I built the first-of-its-kind comprehensive integrated spine care delivery system.
HM: How did you become interested in healthcare policy?
TT: From these different programs, I realized that how we practice medicine has a lot to do with the financial model and policy. So, I went back to school at Loyola University to study healthcare law and policy, and through volunteer work in the public health sector, I was introduced to the legislative and public health side.
HM: What was your most significant conclusion after all that time?
TT: What became apparent is that we need a different labor force for the care model system. A significant mid-level layer, made up of advanced registered nurse practitioners (ARNPs) and physician assistants (PAs), is needed because these professionals have greater reach in the community and can deliver broader care. That is why I started the Physician Assistant Program at Keiser University and served as its medical director before joining Provider Network Solutions.
HM: With your experience spanning the academic, clinical, and public healthcare sectors, what have you found to be the non-clinical factors that contribute to health outcomes today?
TT: I think the cost of healthcare and access to care through the availability of assets or policy limits a lot. For example, certain insurance plans have co-pays that are lower or higher. The structure of that policy makes it harder for certain patients to access the right care at the right time and in the right setting. Patients with higher co-pays may not go to the doctor’s office. While those with a lower co-pay may seek care more often. Another aspect is the environmental factors present where they live. Do individuals have access to doctors’ offices, hospitals, urgent care centers, or even prevention programs? These factors drive healthcare costs for each individual. Physicians are taught to treat the condition or the disease. We don’t do a good job of treating these non-clinical factors that drive patients’ behaviors and ultimately the health outcomes we want to measure.
HM: What role do you think physicians play in better understanding the non-clinical factors that affect their patients?
TT: Medical schools, thankfully, are beginning to integrate that concept more broadly in their curriculum. However, I can safely say that the majority of physicians still focus on treating the patient at the end-stage. They treat symptoms or the illness or disease itself. They don’t have enough knowledge about or the ability to control or address the non-clinical factors. In other words, we can only address the part that we can control, which are the clinical factors.
HM: Do you think physicians want to be able to understand what happens with their patients outside of the clinical walls?
TT: Absolutely. As physicians, we are trained to solve problems. When we know there is a problem, but there is not a tool that gives us a tangible understanding of how we can affect it, then it’s harder for us to do something about it. On the other hand, if we train and have better tools to understand, beyond the clinical information, how we can treat patients, we then have what we need to effect change.
HM: How do you think having this additional information about non-clinical social factors can be used to fine-tune existing care models while remaining fiscally responsible?
TT: When a patient walks into my clinic, right now I can only deal with what’s presented to me and prescribe what to do about it. But if I have more comprehensive information about that patient’s environment and social aspects, it is easier for me to help with the solution.
HM: Do you feel that physicians could use more data-driven insights into what, outside of their clinic walls, could potentially affect their patients’ health?
TT: I think we understand conceptually how non-clinical social factors affect health, but we also feel powerless and frustrated to actually change the outcome, especially in the framework of existing financial models. We need payers to come up with a different payment model that incentivizes providers to take into account the non-clinical factors to treat patients holistically. To get payers on board with that idea, we need a lot more data that shows the benefits of managing those non-clinical risks.
HM: It sounds like if you were to implement an innovative risk-reduction program, you would need to understand the entire continuum, from care aspects to financial impacts to policy requirements.
TT: Right. Currently, I get paid for what I do with patients from a clinical standpoint. If I spend a lot of time dealing with the non-clinical aspects of patient behaviors and eventually improve their health, how do I measure that to show that my time affected change? Right now, there’s no good way to measure that. So, it is better for me financially to focus on taking care of patients strictly from the clinical side, because I can measure and prove outcomes in that realm.
HM: Is that part of the resistance toward value-based care models?
TT: I think so. The understanding is that we all need to move toward value-based care, but the details about how to do that, how it will be structured, and when is what we need to overcome that resistance.
HM: What do you think is needed for stakeholders to put together a more comprehensive plan for value-based care to overcome the resistance?
TT: To me, No. 1 is better data and better information overall to show the benefit of changing our practice and incorporating some of the non-clinical factors as part of our comprehensive care. Until we have these tools, we don’t know how specifically they are connected to patient behavior, how effective we are at changing that behavior or how addressing these factors will affect our business.
HM: As a Chief Medical Officer and Chief Quality Officer of a large Management Services Organization, what would you like to see happen in the next two to three years?
TT: It is difficult to switch from something that is foundational in our infrastructure, such as a fee for service. To switch to something more value-based with more outcomes takes a heavier investment before the patient develops a condition. This switch will require a completely different payment model. We’ll need to understand so much more about the patient and their non-clinical risk factors —their environment— before they step into our office and how all the players can work together in a business model that makes sense for everyone. Until we have the information that could help all of us come up with that model, it will be a challenge.
While providers, like Dr. Tran, and payers must respond to the shift toward value-based care, without necessary tools to translate non-clinical social factors into meaningful data that will help them develop innovative care and payment models, the current trend of addressing healthcare only when people need it will continue. Spatially Health offers insight to respond to patients’ needs before they seek care when it’s more likely to make a positive impact. To find out more, contact us.