While the U.S. healthcare industry largely operates in fee-for-service models, there are pockets of value-based care — including a “unicorn” model in Southern California.
Michael Weiss, DO, vice president of population health for Rady Children’s Health in Orange County, Calif., oversees a CHOC Health Alliance-run capitation model. These VBC models pay providers a “set amount of money per patient, for a set amount of time, for a certain set of services,” according to CMS.
“I know we’re a unicorn, but I oversee a group of 140,000 Medicaid[-covered] children who are under global capitation and have been so for almost 30 years, and we’ve made that work for 30 years,” Dr. Weiss said in an upcoming episode of the Becker’s Healthcare Podcast. “Our doctors are happy, the patients are getting great care and the system works. But I understand that the vast majority of the country is still in a fee-for-service paradigm.”
FFS programs do not reimburse or reward preventive care, counseling or team-based care, Dr. Weiss said. Despite more than three decades of discussions about VBC, adoption has been slow and scattered.
To change that, Dr. Weiss recommends “marrying” clinical and financial goals, like how lowering readmission rates reduces the cost of care. Making VBC financially beneficial requires both C-suite engagement and a payer that believes in it, he said.
“As much as I hate to admit it, in my 40 years [in healthcare], I’ve come full circle and I am semi tainted. Healthcare is a business, and it is all about the money,” he said. “As much as we, as physicians, want it to be all about the quality of care — certainly that’s there, and we’re doing our very, very best. But the reality is, it really comes down to making it work financially.”
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