Providers, payers need to mend relationships to make value-based care system successful

For most of my 18 years as a practicing neurosurgeon, I couldn't fathom working for a health insurance company. What sort of industry, I thought in those pre-2010 days, would be so coldly efficient as to reject anyone with a pre-existing condition as a part of its business model?

Then the Affordable Care Act passed, and five years later, I work for the nation's largest consumer-owned health insurer, an organization with 15 million members.

Why the change? We live in a time when the individual mandate, guaranteed issue and broad consumer protections are the law. Insurers must now provide coverage for people who didn't have access before, even those with pre-existing conditions. 

Consumers benefit from the lowest possible premiums, with payers' administrative costs limited to 15% of premiums for most programs. Providers must care for millions previously locked out of the healthcare system.

As an industry, we have arrived at a moment when even fee-for-service stalwarts see the handwriting on the wall: The current reimbursement system is not sustainable. We must find better ways to align the interests of patients, payers and providers.

I realized, as did many of my colleagues across our industry, that the time is now for value-based care to achieve the “triple aim.” To do this we must mend frayed relationships. In short, we have to work together. But the devil is in the details.

 

Shifting incentives from a model that rewards volume to one that rewards value is a high-wire act. There's a jumble of terms for reimbursement and delivery alternatives—ACOs, HMOs, medical homes, bundled care and others—to help us make this transition. But our system is too big and complex for one model to solve the problem.