Letters: Avoid previous mistakes in move to value-based care

I agree with the tenets expressed by Dr. Clive Fields in his op-ed “COVID-19 exposes flaws in our primary-care system” especially with the need to enhance primary care. Developed countries with an effective primary-care infrastructure commit 10% to 15% of their healthcare spending on primary care, not the 5% the U.S. spends.

The current fee-for-service model has seen significant increases in procedural service reimbursement compared with primary-care reimbursement, with some specialties earning more than twice what a primary-care physician earns. This pay differential is not ignored when medical students choose their ultimate specialty, and it contributes to the scarcity of medical graduates in the U.S. entering primary-care residencies.

The burden of value-based care will fall on primary care. Though the move to value-based payment is important, it is critical that we do not repeat the mistakes of the HMO era. In that model, capitated payment for primary care was based on previous actuarial fee-for-service expenditures. Moving the same amount of reimbursement from fee-for-service to value-based care will only increase primary-care physician burnout, regulatory overhead and complexity unless there are significant positive adjustments to the base reimbursement rate.

To be successful with value-based care, practices will need to hire care managers, quality practice managers and social workers. These adjustments must be made prospectively, and not years after the fact. Primary-care practices do not have the capital to front-load the investment needed to transform to a value-based practice.

Dr. Thomas J. Weida
Tuscaloosa, Ala.

Regarding “HHS launches COVID-19 hospital capacity database,” the Centers for Disease Control and Prevention did not provide standardized, documented counting measures and, as a result, current numbers are unreliable. It makes no sense to maintain an inaccurate database.

The methodology must be stabilized and the sooner the better. I’m amazed that Drs. Anthony Fauci and Deborah Birx, the prominent medical voices on the White House Coronavirus Task Force, advocated “flattening the curve” not based on hospital capacity numbers but rather on predicted COVID-19 volume and then making policies to ensure optimal capacity utilization.

It appears the entire planning process was seriously flawed (if not entirely absent) with insufficient vetting of various actions for rapid targeted mitigation so actions could be adjusted in near real time. Instead, a shotgun-style approach was embraced and it’s a mess.

Michael Cadger
CEO
Monocle Health Data

The article “Chasm grows between Trump and government coronavirus experts,” states: “As the crisis has spread to all reaches of the country, a chasm has widened between the Republican president and the experts. The result: daily delivery of a mixed message to the public at a moment when coherence is most needed.”

There are no coronavirus experts. This is a novel infectious agent; nobody has an expert understanding of the virus nor the public health implications. This has been and continues to be a learning process based on new data, evolving experience, a variety of opinions and limited consensus. Add to this the nightmare of politics and grossly inaccurate reporting. There’s a reality of economic destruction that no ostensible virus expert seems to understand in the slightest. The result is a pragmatism that must suffice until some real expertise evolves over time. Remember HIV/AIDS; it was years before “experts” evolved and there’s still no vaccine.

Dr. Allan Dobzyniak
Eastport, Mich.

Americans living with chronic diseases often face discriminatory practices by health plans, making it difficult to access care. This is particularly true for those living with kidney failure, or end-stage renal disease.

The kidney community celebrated passage of the 2016 21st Century Cures Act, which allowed for both newly diagnosed and existing ESRD patients to enroll in Medicare Advantage starting in 2021. It made sense since MA plans are already available to everyone else enrolled in Medicare.

But CMS recently issued a final rule circumventing congressional intent by making it nearly impossible for ESRD patients to enroll in Medicare Advantage plans.  CMS typically uses “time and distance” standards for MA plans, so patients can find a plan with providers near their homes. But in this rule, CMS exempted outpatient dialysis facilities from these listings. ESRD patients will be discouraged from enrolling in MA because they will be unable to see which dialysis clinics are near their homes. This decision is so alarming that the advocacy group Dialysis Patient Citizens filed a lawsuit against CMS and HHS.

Perhaps the most egregious part of this situation is that kidney failure disproportionately affects Black and Hispanic populations. Patients need clinics close to home. Longer travel to clinics can worsen outcomes and lead to life-threatening complications. CMS is limiting patient choice and giving ESRD patients no option but to remain in the fee-for-service program, often with more out-of-pocket costs and limited care coordination services.

Leaders tasked with safeguarding healthcare should not be permitted to unravel patient protections and quality care that they–and we–have worked so hard to make a priority.

We hope the court will compel HHS and CMS to make things right for all Medicare beneficiaries–including vulnerable kidney patients.

LaVarne A. Burton
President and CEO
American Kidney Fund