Medical students and residents are increasingly learning about value-based care. But aspiring physicians don't have enough opportunity to put that knowledge to work in a healthcare system that mostly relies on fee-for-service payments.
That could hamstring the transition from volume- to value-based care in the long-term.
"If value-based care is the correct way to deliver care, then we should be teaching it within context from the beginning," said Dr. Christopher Moriates, executive director of Costs of Care and assistant dean for healthcare value in the department of medical education at the University of Texas' Dell Medical School.
When it came to educating would-be doctors about value-based care, the conventional wisdom used to be that they should learn about it during or after their residencies. But medical schools and residency programs are including more and more information about how to deliver high-value care to prepare the next generation of physicians for a value-based healthcare system.
Schools like Dell are starting to adopt the Choosing Wisely campaign's principles, which focuses on helping clinicians and patients choose care that is supported by evidence, nonduplicative, free from harm and necessary. "When I was in medical school, I was never taught about the harms of overuse or the scope of the problem," Moriates said. "You were basically rewarded for thinking up more and more tests or diagnoses. You could only gain points by doing more."
Dell's first-year students study cases that urge them to think about issues related to costs, social determinants of health and outcomes that matter to patients during their first week. "It changes the way they learn the rest of their medical school curriculum," Moriates said. Value-based care is "woven throughout the curriculum in ways that … our students don't even recognize because that's all they've ever known."
Experts said students and residents must understand value-based care's purposes and goals and how to provide high-value care. "You're giving them these value-based glasses to view the world, and once they've got those glasses on … they really view everything else they learn in medical education differently," Moriates said.
Yet medical students and trainees have not been taught how clinicians and health systems' financial incentives affect healthcare delivery until recently. Experts said educators can teach early career clinicians how different reimbursement models encourage specific behaviors among providers without getting into payment model details.
Dr. Keith Horvath, senior director of clinical transformation for the Association of American Medical Colleges, said education about value-based care is most likely to have an impact during and after residency when physicians start delivering care to patients in the real world. "The (medical school) curriculum is already jammed (and) value-based care is still a moving target," Horvath said.
He pointed to the CMS Innovation Center's ongoing experiments with value-based payment, noting that the agency kickstarted several new payment models this year and that the agency probably won't make any of them permanent. Most providers learn about value-based payment models through webinars and other continuing education through specialty societies.
But "medical schools are probably a little further along than residency programs, specifically when it comes to value-based care," said Dr. Ryan Murphy, co-director of the value-driven healthcare pathway for medical students at the University of Utah School of Medicine.
He said it's easier to change the medical school curriculum than to retool residency programs because medical schools only have one class at a time compared to dozens of residency programs. Accrediting organizations have driven significant changes to residency programs in recent years. But residents still mostly learn about high-value care through day-to-day clinical practice, Murphy said.
AAMC's Horvath said it's often difficult for residents to experience the care coordination and management benefits of value-based care because they have limited exposure to patients beyond the inpatient setting and don't regularly interact with the same patients.
Several experts lamented the lack of opportunities for new physicians to practice value-based care. "You can teach people about different models of care, but unless they have the opportunity to practice in those models, it's going to be difficult for them to get to know it," said Dr. Daniel McCarter, national director of primary care advancement at ChenMed. "You're not going to learn value-based care by just reading about it."
Yet, most residencies take place in hospitals, which are reimbursed mainly through a fee-for-service payment model. Residents learn to practice volume-based medicine because that's what providers get rewarded for. ChenMed's McCarter said new physicians "come in with very little exposure to the costs of healthcare or the outcomes." He argued they need to learn how to take responsibility for a panel of patients, deliver high-quality customer service, manage finances and take on leadership roles.
Experts said the healthcare system needs to develop better ways to transition hospitals and group practices from fee-for-service reimbursement to risk-bearing, value-based payment models because they encourage hospitals to deliver value-based care. "The reimbursement models are the single biggest lever to moving change," Utah's Murphy said.
Dell's Moriates said it's essential for medical students and residents to understand that they're learning to practice value-based care because "providing high-value care is being a good doctor."
"But if that's not actually rewarded … it's easy to say, 'what we talk about what is one thing and what we actually value is another," he said.
Moriates worried that providers focus too much focus on how "Medicare is changing the rules and making it seem like there's this burden on us."
Experts suggested policymakers could encourage medical schools and residency programs to include more value-based care in their curriculum and training by conditioning graduate medical education funding conditional on it. They could also give clinicians more access to information about costs, quality and outcomes.
But it will take a full-throated effort from the entire healthcare industry to make faster progress.
Dr. Michelle Hofmann, co-director of the value-driven healthcare pathway for medical students at the University of Utah School of Medicine, would "love" consumers, insurers and other stakeholders to help develop and participate in value-based care education programs for providers since existing initiatives like the Choosing Wisely campaign mostly involve medical students, residents and educators.
