“In value-based care, it’s mandatory that we as physicians are part of these conversations both on the cost side as well as on the spend side, so we need access to the total cost-of-care data we’re being tied to and judged by,” said Dr. Harrill. He also said it’s mandatory that physicians drive the discussion on the quality benchmarks they’ll be judged by and ensure that accurate disease severity and patient comorbid health risks are factored into cost benchmarks.
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October 2023Although otolaryngology hasn’t been forced to move to VBC, a shift from FFS to VBC is happening throughout the healthcare system from its initial implementation in primary care after the 2010 Affordable Care Act and the 2015 MACRA legislation. More specialists are engaging with VBC, including cardiology, orthopedics, nephrology, and oncology; it’s rapidly moving toward implementation in general surgery, gastroenterology, and pulmonology.
Dr. Harrill believes that it’s in otolaryngology’s best interest to learn about the process to ensure that the specialty has the necessary infrastructure to operate in this shifting payment landscape. He underscored the fact that APMs such as VBC are a complex, data-driven business model requiring new learned skills and analytics to succeed.
In 2026, CMS will roll out new patient episodic care models. Whether or not otolaryngology will be a part of that is unknown at this time. Despite CMS’s decision, however, otolaryngology will face increasing challenges in reimbursement and coverage within an FFS payment model in an environment in which primary care and other specialties are implementing an APM. Specialist referrals will begin to track toward what the system views as high-value specialists.
That said, Dr. Harrill said that it takes years to transition from FFS to APM, and that he doesn’t see otolaryngology FFS payments being less than 70% of the revenue streams in the next seven years. “It’s inevitable that otolaryngology will engage in value-based care,” he said. “We’ll never be over 30% APM based on the total cost-of-care variation for our services compared to other specialties.”
Otolaryngologists will, however, be engaging referrals from physicians who make most of their salary in APM contractual arrangements, he noted. “They’ll care a lot about how we manage our FFS patients because that will directly impact the salary of those who refer to us,” said Dr. Harrill, adding that future wrangling about denials and prior authorizations may happen directly with referring physicians if otolaryngologists don’t start paying attention to the necessary infrastructure for cost transparency and begin learning about APMs.
Mary Beth Nierengarten is a freelance medical writer based in Minnesota.