“The Fall Will Probably Kill Us”

In one of my favorite scenes from one of my favorite movies, Butch Cassidy and the Sundance Kid are arguing on a rock cliff overlooking a raging river over who should jump first to get away from the Pinkerton detectives who have been chasing them down for robbing the Union Pacific Railroad. “We have to jump”, says Butch. “We can’t, says Sundance, I don’t know how to swim!” “Well hell”, Butch retorts, “the fall will probably kill us”.

This is a scene and a conversation that I often imagine as I hear healthcare providers and payers argue who should go first in moving toward a more value-based model of care delivery or care reimbursement. I’ve spent countless hours during my years as a healthcare consultant hearing providers, especially, hospital and healthcare system managers, argue that they can’t move to a more accountable care model in that the payers aren’t offering enough incentives to do so. Similar meetings with payers bring the same excuses, “we would be glad to offer value-based reimbursements, e.g. bundled payments, shared savings agreements, or capitated population health management arrangements, but none of the providers are set up to deliver care under such arrangements.”

To both of these groups, I counter — “Well hell, the fall is probably going to kill you both!”. In other words, if things don’t move from the current high-volume, high-cost, relatively poor quality (especially for preventive, primary, and chronic care services) to a more high quality, low cost, value-based model then both providers and payers will be killed in the fall as legislated healthcare reforms erode what’s good about our current healthcare system.

We are lucky in this country to have many highly-skilled,well-trained physicians and other caregivers, access to innovative high-tech equipment, and life-saving acute care delivery systems for conditions such as Level I trauma, oncology, cardiac disease, orthopedics, obstetrics, neonatology, and neurosurgery. We must not erode the quality of the above through poorly considered political reforms, but instead, cut out the tremendous amount of waste in our current system and incentivize improvements in primary care, preventive care, public health, behavioral health, and other areas.

Payers and providers need to jump simultaneously and not wait for the other to go first. Right now, neither one is able to swim effectively in a value-based stream, but if they don’t jump in together, we’ll all drown in a political vortex that we should try and avoid.


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Ellis Knight

Semi-retired physician and healthcare executive / consultant spending my time advocating for value-based care reform in the US healthcare system.