When we gamify a good thing, we rarely win.
When I was a kid living in South Akron, Ohio, Guiseppe’s Pizza was the place. A tiny, hole-in-the-wall joint with fresh sauce and hand-shredded cheese, it always served up pie that was warm and delicious. For a while, they even threw an extra slice on top of the pizza box and called it “one for the road.” Then I moved to Marion, the heart of farm country. It was flat as a pancake, with nothing but corn silos, soybeans, and winter wheat as far as the eye could see. But tucked into a grungy corner store-front was Tubby’s Pizza — thin, like a cracker, with hand-sliced pepperoni that would curl and fill with grease when cooked. Two completely different pizzas, but I (the consumer) judged them both to be really good.
WHAT IF PIZZA MAKING WAS LIKE PATIENT CARE
A recent Health Affairs Forefront article1 argued that value-based care (VBC) is not a payment model but a contest (an “adjudication system”) in which the rules of the game are as important as the outcome. Not only that, but the rules determine the outcome.
It would be akin to a pizza-making contest, as opposed to a payment model (i.e., sell pizzas, make money). Before we start baking, some nameless judge writes down what score will count as a win. We need to make a pizza as good as or better than that to be successful. So we bake, and we sell — all year long. At this point, we don’t know if we’ve beaten the benchmark. We think we have, because we’re doing all the right things, but we don’t know.
Two years later, the judge compares our pizza against the benchmark — after applying some rules in the fine print. This decides which pizzas count as ours (attribution), how the target gets calculated (benchmark rules), and whether we can appeal (reconciliation). Oh, and the judge can change the rules at any point, even though we’ve already baked the pies.
That’s what happened in 2024 with VBC. The Accountable Care Prospective Trend (ACPT), a projected growth rate used to establish spending targets for the Medicare Shared Savings Program, was set at 4.9%, but the actual rate was nearly double.2 This means high-performing accountable care organizations (ACOs) that held their costs below the market missed the target. This wasn’t due to bad intent, just unpredictability, so Medicare changed the rules and cut the ACPT weighting in half, softening the blow to ACOs.
A common source of frustration with VBC arrangements is that they “do not compensate providers for value at the time value is produced.”1 Delayed rewards create a disconnect between our work and our ability to improve it. If I made a pizza two years ago but I’m judged on it today, how am I supposed to make changes on something in the past? What if I’ve been doing it wrong since then? What good things have I been doing that I can build on? All of these opportunities are lost.
So many factors in VBC are beyond our control, such as benchmarking. No wonder physicians feel exhausted by the gamification of the system, hunting for “HCC” and patient satisfaction scores to look good on a spreadsheet. The contest feels disconnected from the care.
SOME GOOD NEWS
You know who makes amazing pizza? Bakers. And you know who takes amazing care of patients? Primary care physicians.3 In fact, ACOs made up of predominantly primary care clinicians save more money than other ACOs — $403 vs. $224 in net per capita savings, respectively.4
I’m back in Akron as an adult, and although Guiseppe’s is on the other side of town, I still get it every once in a while and it’s still amazing. And when I’m back in Marion visiting family, it’s Tubby’s. Two bakers, two approaches, one outcome: darn good pizza!
