CMS seeks input on Stark Law changes amid value-based care shift

https://www.healthcaredive.com/news/cms-seeks-input-on-stark-law-changes-amid-value-based-care-shift/526239/

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Dive Brief:

  • The Centers for Medicare & Medicaid Services asked stakeholders Wednesday for input on how to change the Stark Law to allow for better care coordination and new alternative payment models or other novel financial arrangements.
  • The American Hospital Association has been vocal in pushing for changes to the physician self-referral law, calling it outdated. AHA argues the law presents “nearly impenetrable roadblocks in the move toward value-based care.”
  • The agency specifically is requesting input on what new exemptions to the Stark Law are needed to protect accountable care organization models, bundled payment models and other payment models, including how to allow coordination care outside of an alternative payment model. It also asks for help examining definitions for terminology such as risk-sharing, enrollee, gain-sharing and other terms.

Dive Insight:

The Stark Law, enacted in 1989, aims to cut down on financial incentives impacting physician care decisions. It prohibits certain Medicare-payable referrals to entities they have a financial or familial relationship with, and stops such entities from filing Medicare claims for referred services, unless exempted under certain instances.

CMS says that it is issuing the RFI in response to comments it has received that raised concern that the Stark Law is impeding participation in healthcare delivery and payment reform efforts.

“We are particularly interested in your thoughts on issues that include, but are not limited to, the structure of arrangements between parties that participate in alternative payment models or other novel financial arrangements, the need for revisions or additions to exceptions to the physician self-referral law, and terminology related to alternative payment models and the physician self-referral law,” the CMS notice states.

In a statement submitted by AHA to the House Subcommittee on Health of the Committee on Ways and Means, the group urged Congress to step in to change Stark Law to allow hospitals and physicians to more closely work together.

“Congress should create a clear and comprehensive safe harbor under the anti-kickback law for arrangements designed to foster collaboration in the delivery of health care and incentivize and reward efficiencies and improvement in care,” AHA said.  “In addition, the Stark Law should be reformed to focus exclusively on ownership arrangements. Compensation arrangements should be subject to oversight solely under the anti-kickback law.”

CMS Administrator Seema Verma appears to be sympathetic. In a Wednesday blog post, she said the Stark Law may be prohibiting value-based arrangements that HHS has made a priority to shift towards. Previously, Verma said that CMS was going to put together an inter-agency group to examine potential changes to the law.

“I think that Stark was developed a long time ago, and this gets to where we are going modernizing the program,” Verma told AHA President and CEO Rick Pollack during a webcast in January. “The payment systems and how we are operating is different, and we need to bring along some of those regulations and figure out what we can do. And I’m not sure that this is not going to require some congressional intervention as well.”

CMS is asking for comments to be submitted on the RFI by August 24.

 

‘No profit, no mission’ — Why this CEO believes every healthcare leader needs a strong understanding of finance

https://www.beckershospitalreview.com/hospital-management-administration/no-profit-no-mission-why-this-ceo-believes-every-healthcare-leader-needs-a-strong-understanding-of-finance.html

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In this special Speaker Series, Becker’s Healthcare caught up with Mark R. Anderson, CEO of AC Group, a healthcare technology and advisory research firm based in Montgomery, Texas.

Mr. Anderson will speak on a panel at Becker’s Hospital Review 7th Annual CEO + CFO Roundtable titled “The CEO paradox: Can you really have volume and value?” at 12:00 p.m. on Monday, Nov. 12. Learn more about the event and register to attend in Chicago.

Question: What keeps you excited and motivated to come to work each day?

Mark Anderson: The knowledge that we are finally moving away from fee-for-service billing to value-based reimbursement. For example, at AC Group, we have been able to cut medical costs for diabetic patients by 38 percent just by tracking blood sugar levels at home. Pay for results — don’t pay for just seeing the patient.

Q: What major challenges, financial or otherwise, are affecting hospitals in the markets you serve? How is your hospital responding?

MA: With hospital bankruptcies on the rise, we need to change how we deliver cost effective care and how we are paid. Because of high deductible health plans, the patient portion of the bill has increased from 9.4 percent in 2019 to 26.9 percent in 2017. How do we collect from the patient? How can we share clinical information about the patient with all providers without hurting our financial position?

Q: What initially piqued your interest in healthcare?

MA: It was my high school graduation present from my father. I wanted a trip to Hawaii and all I got was a letter stating, “Congratulations for finishing in the top 4 percent of your high school class. For your reward, you start work on Monday as the statistician for the hospital CEO.” Forty-five years and 250 hospitals later, I am still in hospital executive management.

Q: What is one of the most interesting healthcare industry changes you’ve observed in recent years?

MA: To name a few: Moving to electronic billing in 1985, moving from spending 2.1 percent on IT in 2005 to over 6.5 percent today (was it worth it?), forcing physicians to become data entry clerks so we can maximize coding with very little improvement in “health,” and moving to value-based reimbursement from fee-for-service so we are finally paid on quality, outcomes and our ability to lower costs through care coordination and remote patient monitoring. The four walls of the hospital are not the only care delivery system. Ninety-five percent of healthcare is delivered in the home.

Q: What is one piece of professional advice you would give to your younger self?

MA: Don’t enter the healthcare market without a strong financial knowledge base. Healthcare is a business. As the nuns told me back in 1976, no profit — no mission to help the poor and disadvantaged.

 

 

 

Do Most Hospitals Benefit from Directly Employing Physicians?

https://hbr.org/2018/05/do-most-hospitals-benefit-from-directly-employing-physicians

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How can hospitals and health systems generate a return on their investment in their physician enterprises? According to the most recent figures, from the American Medical Association, over 25% of U.S. physicians practiced in groups wholly or partly owned by hospitals in 2016 and another 7% were direct hospital employees. Yet, according to the Medical Group Management Association, hospitals’ multi-specialty physician groups lost almost $196,000 per employed physician.

As a result, some larger health systems’ physician operations are generating nine-figure operating losses, which are major contributors to the deterioration in hospital earnings.  It is time for hospitals or health systems to rethink their strategy for their physician enterprises.

Let’s first revisit why independent physicians were receptive to becoming employees and why hospitals and health systems felt the need to hire them.

The surge in hospital employment of physicians predated Obamacare by at least six years, and had two key drivers. The first was independent baby-boomer physicians — particularly those in primary care — found themselves unable to recruit new partners. Newer physicians, heavily burdened by student debt, were not inclined either to take on entrepreneurial risk or the 60-hour work weeks independent practice entailed.

The second was cuts in Medicare payments for office-based imaging. Thanks to the Deficit Reduction Act of 2005, specialties such as cardiology, orthopedics, and medical oncology that relied on the revenue that imaging generated were hit hard. As a result, many found it advantageous to be employed by hospitals. Under Medicare rules, in addition to professional fees, hospitals can charge a Part B technical fee for their services and therefore can pay practitioners more than they could earn in private practice.

Then, beginning in 2009, the Obama administration’s policies increased the exodus of physicians from private practices to health systems. The “meaningful use” provisions of the HITECH Act of 2009 provided both incentives and penalties for physicians to adopt electronic records, but hospitals and very corporate enterprises had more resources to comply with meaningful-use requirements.

The value-based-payment schemes created by the Affordable Care Act also markedly increased documentation requirements and, as a result, the overhead of practices, driving more physicians into hospital employment models.

There have been a number of reasons hospitals have been hiring physicians. Some, particularly those in rural areas, had no choice but to turn physicians into employees. Retiring independent physicians were leaving large gaps in care in their economically challenged communities. Consequently, hospitals that did not step in to fill the gaps were in danger of closing.

Separately, some hospitals or systems sought to grab business from their competitors by acquiring physicians who hospitalized their patients at competing facilities. These physicians’ inpatient and, particularly, outpatient imaging and laboratory volume generated additional revenues for the acquiring hospital or system.

A third apparent motivation was to corner the local physician market in order to obtain more favorable rates from health insurers. This seemed to have been a major rationale for St. Luke’s Health Systems acquisition of Seltzer Medical Group, Idaho’s largest independent, multi-specialty physician practice group, which led to an anti-trust action.

Yet another reason for making physicians employees was to position the organization for capitated, or value-based, payment. Hospitals believed that “salarying” physicians would help control clinical volumes and thus make it easier to perform in capitated contracts.

Finally, some hospital and system CEOs were tired of negotiating with local independent physician groups or national physician-staffing firms like MedNax and TeamHealth over incomes and coverage of the hospitals’ 24/7 services such as the emergency department, the intensive care unit (ICU), and diagnostic services like radiology and pathology. Building an in-house staff of physicians seemed like an attractive alternative.

Many health systems have gotten into trouble because their strategic rationale for hiring physicians became a moving target.  A hospital system we followed morphed from a ““grab market share” strategy to a “respond to competitive acquisitions” strategy to a “bailout” strategy for loyal independent physicians to a “increase bargaining power with payers” strategy to a “position for value-based care” strategy over a period of eight years. By the time it was done, it was the proud owner of a 700-plus physician group and losses of more than $100 million per year.

Hospitals lose money on their employed physicians because physicians’ compensation plus practice expenses and corporate overhead significantly exceed the collections of practices. These direct losses are, to a degree, an artifact of accounting, because hospitals frequently do not attribute any bonus for meeting “value-based’ contract targets, or incremental hospital surgical, imaging, and lab revenues to physician practice income.

However, even factoring in the accounting issues, much of the losses are attributable to “hosting,” rather than managing, practices effectively.  Many systems employing physicians have done so without developing a cohesive physician organization and lack standardized staffing and operational support functions, such as effective purchasing and supply chain operations, effective scheduling systems, and centralized office locations.

Managing up the return, rather than managing down the loss, is the key to a successful physician strategy. Here’s how to do that.

Establish a clear strategic goal and a target return on investment. Physicians reside at the core of any successful health system. Yet as the Cheshire Cat said in Alice in Wonderland, “If you don’t care where you are going, then it doesn’t matter which way you go!” If you establish strategic goals for the physician enterprise, then the physician organization can be sized and located appropriately. As a result, the physician group may end up either a lot smaller or with a more defensible specialty and/or geographic distribution. Management should then quantify and budget the expected return on the practice’s operational loss.

Strengthen operations. Effective management of the physician group then becomes the essential challenge. For example, revenue-cycle issues such as inconsistent coding or missing data often damage the profitability of the medical group. Are systems in place to assure that medical bills are defensible and correct, and that patients understand what they owe and agree to pay? Seeing that encounters are adequately documented and translated into a fair and timely bill that patients are willing to pay is not rocket science. The return on investment for getting the revenue cycle right is often 3X to 5X.

Revamp compensation and incentives. Medicare’s policy for paying employed physicians will likely come under fresh scrutiny during the Trump administration. It is possible that Medicare’s relatively favorable payment for hospital-employed physicians will be reined in. If that happens, it might require a painful revisiting of employment contracts when they come up for renewal.

Performance incentives in those contracts should also match the strategic goals established above. For example, compensating physicians through a production-based model that encourages them to increase visits, procedures, or hospital admissions, while value-based insurance contracts (like those for accountable care organizations) demand reducing them could damage the overall performance of the health system.

Pursue reality-based contracts with insurers. The Affordable Care Act ushered in a profusion of narrow network, performance-based contracts with private insurers, with significant front-end rate concessions by hospitals. These discounts often far exceeded the potential rewards from the “value based” incentives in the contracts! Larger health systems also rushed to assemble “clinically integrated networks” (CINs), comprising their employed and contracted physicians as well as private practitioners in their markets, to participate in these new contracts. Treating physician group losses and CIN expenses as loss leaders for value-based contracts and then losing yet more money on those contracts, as is happening in many places, doesn’t make sense.

Both enrollment and financial performance under these contracts have been disappointing in most markets. Reviewing and pruning back these contracts, or renegotiating them to provide more adequate rates or to compensate hospitals for patient non-payment is an essential element of an effective physician-enterprise strategy. Hospitals and health systems also should ask: “Is the CIN functioning as intended? Is it adding value that patients notice or is it just an additional layer of administrative expense without compensating benefits for clinicians or patients?

Motivate employed and independent physicians. Finally, hospitals and systems must understand the value they are creating not only for their employed clinical workforce but also for the two-thirds of their physicians who are not full-time employees — those who are contracted, independent participants in CIN’s or in part-time administrative roles. What would motivate all these physicians to want to work with the organization over the long term?

Hospital and systems need a unified physician strategy and operating model that encompasses all these diverse arrangements. Beyond that, they must  engage their physicians in planning and organizing care. Physician are complex, highly trained professionals. They cannot be mere employees; they must be owners of the organization’s goals and strategies.

 

 

 

What value-based care really needs: change management

http://www.healthcarefinancenews.com/news/what-value-based-care-really-needs-change-management?mkt_tok=eyJpIjoiWXpKbVlqbGxNREE0WWpsbSIsInQiOiJVaVI2M1wva2VlZDZScVVUNHcyb0NwdVVpYmQrR3V6QitlSXVFYzNmWXh0ZWd5TTRydXdhRlY0d2xmeUZseEgxNHNDVTRlS3ZwbGJFdlRVZ01OQXRlc0Y5VnFLelFiK3JySFp6UVBodmpjNWh1bituNHNLZ2F2OXIwUTRRTTRmVkIifQ%3D%3D

The transition is one careers will be built on, if health executives align their delivery systems properly, deploy analytics, and maintain focus.

Hospital executives have a tough balancing act regarding the transition to value-based payment models. While the industry is steadily moving toward this new framework, many providers and services still operate on the old fee-for-service model, which is becoming more and more obsolete. That means C-suite leadership has to make the switch to value a high priority for their organizations.

They’re under tremendous pressure these days. There’s been a significant market shift. Providers and their associated patient panels — a list of patients assigned to each care team in the practice — are shifting toward government business, and government business has a more pronounced focus on value-based care.

According to Jeff Smith, senior vice president of U.S. markets at Lumeris, the move to value has been accelerated by a shift in payer mix away from commercial and more toward Medicare, which yields lower margins. And the commercial rates providers have been receiving are on the downswing.

“Underlying their business model today, health systems have to profitably manage their fee-for-service business while making this transition to value,” Smith said. “It’s like having one foot on the dock and one in the canoe. They often don’t have the understanding or expertise to make that strategic shift and successfully move toward value. It’s a new frontier for many of these providers.”

What providers need, said Smith, is more robust alignment with their delivery system around the new model. It’s about having an engaged, aligned network that focuses not just on the patient in front of them, but on an entire population.

“It really is an enterprise-wide change management initiative. This the kind of transition that careers are built on,” Smith said. “Some of the things they need to avoid are embarking on this journey with a lack of, I would say, panel density, and aligned incentives with their physician network. It’s problematic if this is nothing more than a nuisance. It really has to be a strategic focus.”

An organization also has to have the right governance and leadership in place, he said. Even though something worked under the old model, it’s a mistake to assume that it will naturally evolve and adapt to the new. A successful transition requires significant practice transformation.

All that, and an organization still has to maintain a high standard of care. That’s where advanced analytics come in.

“It really requires an understanding of where the opportunities are,” Smith said, “and that’s driven by advanced analytics and practical insights, and where to apply their investments to get the maximum return. They also need to have a really strong plan in governance, and this really requires support from the C-suite. It has to start with the CEO.”

Because every hospital, health system and physician practice is different, a good place to begin is with a market assessment of provider and business opportunity, which can show how to align strategies around a blueprint for successful profitability. Alignment truly is a key component of success, as everyone needs to be on the same page, from the CEO down to the physicians delivering care.

And time is of the essence. Smith expects the journey to value to be near-complete within about three years.

“The transition has been remarkable to me,” he said. “The amount of change we’re seeing year over year is remarkable. It was primarily led by these government programs, but the private payers have really adopted a lot of these changes. There are significant changes in the payer community in general, and more to come.”

 

Paying Hospitals To Keep People Out Of Hospitals? It Works In Maryland.

Paying Hospitals To Keep People Out Of Hospitals? It Works In Maryland.

Saturdays at Mercy Medical Center used to be perversely lucrative. The dialysis clinic across the street was closed on weekends.

That meant the downtown Baltimore hospital would see patients with failing kidneys who should have gone to the dialysis center. So Mercy admitted them, collecting as much as $30,000 for treatment that typically costs hundreds of dollars.

“That’s how the system worked,” said Mercy CEO Thomas Mullen. Instead of finding less expensive alternatives, he said, “our financial people were saying, ‘We need to admit them.’”

Maryland’s ambitious hospital-payment overhaul, put in place in 2014, has changed such crass calculations, which are still business as usual for most of American health care. A modification of a long-standing state regulation that would be hard to replicate elsewhere, the system is nevertheless attracting national attention, analysts say.

As soon as Mercy started being penalized rather than rewarded for such avoidable admissions, it persuaded the dialysis facility to open on weekends, saving government insurance programs and other payers close to $1 million annually.

In the four years since Maryland implemented a statewide system of pushing hospitals to lower admissions, such savings are adding up to hundreds of millions of dollars for the taxpayers, employers and others who ultimately pay the bills, a new report shows.

Maryland essentially pays hospitals to keep people out of the hospital. Analysts often describe the change as the most far-reaching attempt in the nation to control the medical costs driving up insurance premiums and government spending.

Like a giant health maintenance organization, the state caps hospitals’ revenue each year, letting them keep the difference if they reduce inpatient and outpatient treatment while maintaining care quality. Such “global budgets,” which have attracted rare, bipartisan support during a time of rancor over health care, are supposed to make hospitals work harder to keep patients healthy outside their walls.

Maryland’s system, which evolved from a decades-old effort to oversee hospitals as if they were public utilities, regulates all hospital payments by every private and government insurer. That makes it radically different from piecemeal attempts to lasso health spending, such as creating accountable care organizations, which seek savings among smaller groups of patients.

From the program’s launch in 2014 through 2016, per capita hospital spending by all insurers grew by less than 2 percent a year in Maryland. That’s below the economic growth rate, according to new results from the state’s hospital regulator and the federal Department of Health and Human Services.

Keeping hospital spending below economic growth — defined four years ago as 3.58 percent annually — is a key goal for the program and something that rarely happened.

Counting The Savings

The state plan saved the Medicare program for seniors and the disabled about half a billion dollars over three years and achieved “substantial reductions in hospitalization and especially improvements in quality of care,” said a Medicare spokesman.

In the three years measured so far, he added, “the state has already exceeded the required performance for the full five years of the model.”

As high costs for hospital care have been growing more slowly nationwide, Maryland hospital costs over that period rose even less.

“It looks like it has very strong results,” said John McDonough, a Harvard health policy professor who helped craft the federal Affordable Care Act.

What Maryland is doing, he said, “is pretty bold and it’s pretty thoughtfully done and has generated a huge amount of interest around the country.”

Comprehensive results through 2016 are the most recent available from Maryland and HHS, although savings continued last year, Maryland officials said. Independent researchers found mixed results for savings in the earlier years of Maryland’s system.

Maryland’s global budgets saved Medicare $293 million — 1.8 percent of total Medicare spending — in 2014 and 2015, research firm RTI International reported in August.

A separate paper from a team led by Eric Roberts at the University of Pittsburgh found that Maryland’s program in those years couldn’t be clearly credited for reducing hospital use.

The system’s advocates say several years of results are needed to show it’s working.

“These are not fake savings,” said Joseph Antos, an economist at the conservative-leaning American Enterprise Institute who sits on Maryland’s hospital-payment commission. “It didn’t happen instantaneously. It’s taken this number of years to achieve the kinds of savings that you see” for 2016 and beyond.

Even boosters such as Joshua Sharfstein, the former Maryland health secretary who got approval for global budgets from the Obama administration, say the system is far from perfect or finalized.

“There is a range of responses. Some hospitals have been able to do more than others,” said Sharfstein, now an associate dean at the Johns Hopkins Bloomberg School of Public Health in Baltimore. “Change in health care is notoriously slow.”

Hospitals have lagged in delivering primary, preventive care to people with chronic conditions such as asthma, diabetes and heart failure, especially in low-income neighborhoods.

Maryland’s system does little to control soaring costs of drugs or nursing home care, doctors’ office treatments and other care not connected to hospitals, although policymakers are working on proposals to do both.

Even so, “what Maryland has done is just so far ahead of many of these other models” to try to control costs, said Dan D’Orazio, a management consultant who has worked with hospitals across the country. One Maryland hospital CEO told him: “This has fundamentally changed how we wake up and do business every day,” D’Orazio said.

Seeing A Difference

At Mercy, described by policymakers as more aggressive than many hospitals in watching costs, about a third of the patients now leave the hospital with medications in hand, said Dr. Wilma Rowe, the hospital’s chief medical officer. That bypasses the tendency for patients to skip a follow-up pharmacy visit and risk landing back in the emergency room.

A statewide data network notifies Mercy and other hospitals when one of their patients ends up in an emergency room somewhere else. That helps coordinate care.

Greater Baltimore Medical Center, north of the city, has hired dozens of primary care doctors to track around 1,000 people with diabetes — staying in touch, advising on diets and keeping them on insulin so they avoid the hospital.

Often clinicians visit elderly patients’ homes to prevent what might turn into an ambulance call and admission, said the hospital’s CEO, Dr. John Chessare.

Before global budgets, “I’d look at the waiting room in the [emergency department], and if it wasn’t full I’d get scared,” he said.

Now he worries it might be full of people who could be better treated elsewhere — including Gilchrist, a GBMC affiliate delivering hospice care for those at the end of life.

These days, he said, “we consider it a defect if someone with chronic disease dies in the hospital.”

 

 

Healthcare execs say EHRs don’t do enough to manage value-based contracts

https://www.healthcaredive.com/news/healthcare-execs-say-ehrs-dont-do-enough-to-manage-value-based-contracts/518330/

Dive Brief:

  • A survey of 100 healthcare executives found that most of them are seeing ROI on value-based contracts, but investments in EHRs are not sufficient to manage those contracts.
  • The Sage Growth Partners study found most respondents were not satisfied with their EHRs’ “ability to help them manage core functions necessary to succeed in (value-based care) — such as care coordination, risk stratification, decision support and patient engagement.”
  • About two-thirds of respondents said EHRs are not delivering promises concerning lower costs, better population health management and improved patient and physician satisfaction.

Healthcare providers are increasingly looking to EHRs and third-party population health management solutions to help them with value-based care.

A recent Healthcare Financial Management Association (HFMA) survey found that value-based payment programs doubled since 2015. Nearly three-quarters of executives in the HFMA survey said their organizations achieved positive financial results, including return on investment, from value-based payment programs.

Although providers expect value-based programs to continue to increase, the new Sage Growth Partners survey found dissatisfaction with EHRs and concern they are not helping enough in value-based care. The report found 64% of respondents said EHRs haven’t delivered many critical value-based tools. At least 60% of respondents said they are looking for value-based solutions beyond EHRs.

The survey included a finding that will likely get the attention of EHR and population health management vendors — half of respondents said they are somewhat or highly likely to switch population health management vendors over the next three years.

Nearly three-quarters of survey respondents have had an EHR for at least three years. About half also have third-party population health management solutions. These findings offer a glimpse into the dissatisfaction as well as opportunity in population health management.

The executives surveyed said there are issues with interoperability, addressing social determinants of health, patient engagement, stakeholder coordination and risk analytics. They also spoke of health systems having trouble aggregating and using data from numerous EHR systems and other data sources.

These issues have led half to two-thirds of healthcare executives turning to population health management or do-it-yourself solutions beyond EHRs “to compensate for the lack of these capabilities within their EHRs.” Many of those executives said population health management solutions enabled their value-based success. Those successes are also coming at a lower cost than the investments in EHRs.

The study authors predicted more healthcare executives will look beyond EHRs in the coming years to help with value-based contracting. They said “suboptimal tools” that manage care and costs for populations won’t be enough in coming years.

“As (value-based care) reaches the tipping point, and as they take on programs with greater risk and greater complexity, they will need to continue looking beyond their EHRs to get the functionality they need,” the authors wrote.

 

We Won’t Get Value-Based Health Care Until We Agree on What “Value” Means

https://hbr.org/2018/02/we-wont-get-value-based-health-care-until-we-agree-on-what-value-means

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Some health care leaders view with trepidation the new, disruptive health care alliance formed by Amazon, Berkshire Hathaway, and JPMorgan Chase. But I’m excited because disruption is all about delivering a new level of value for consumers. If this trio can disrupt the United States’ health care system into consistently delivering high-value care, we will all owe them our gratitude.

First, their leaders — Jeff Bezos of Amazon, Warren Buffett of Berkshire Hathaway, and Jamie Dimon of JPMorgan Chase — must think deeply about what “value” actually means for the companies and individuals they will serve and for the people and organizations they will engage to deliver care.

Then they need to consider how they will bridge the divergent interpretations of value. It turns out one reason there’s been such little progress in creating a value-based system is that the stakeholders in the U.S. health care system — patients, providers, hospitals, insurers, employee benefit providers, and policy makers — have no common definition of value and don’t agree on the mix of elements composing it (quality? service? cost? outcomes? access?).

That’s the big takeaway of University of Utah Health’s The State of Value in U.S. Health Care survey. We asked more than 5,000 patients, more than 600 physicians, and more than 500 employers who provide medical benefits across the nation how they think about the quality, service, and cost of health care. We focused on these groups because we feel their voices have not been heard clearly enough in the value discussion. What we discovered is that there are fundamental differences in how they define value in health care and to whom they assign responsibility for achieving it. Value, it seems, has become a buzzword; its meaning is often unclear and shifting, depending on who’s setting the agenda. As a result, health care stakeholders, who for years thought they were driving toward a shared destination, have actually been part of a fragmented rush toward different points of the compass.

But the Utah survey’s findings also suggest a straightforward (though not simple) way to overcome this confusion: stop, listen, and learn. The most effective thing that stakeholders can do to create a high-value health care system is to pause in their independent pursuits of value to describe to each other exactly what it is they seek. Jumpstarting this stakeholder dialogue will require real leadership from executives in business, health care delivery, academic medicine, and patient advocacy groups. They’ll have to muster the courage to say to their constituencies, “The path toward value that we charted may not have been the right one.”

Those dialogues should happen at three levels: nationally, among representatives of stakeholder groups; institutionally, among partners in the care delivery process; and individually — for example, between patients and their physicians, and between employer sponsors of health plans and their employee beneficiaries.

There are several examples of the fundamental value misalignments that could be starting points for these discussions. The first concerns the relative importance of health outcomes. For physicians like me, clinical outcomes are paramount; health improvement and high-quality care are essential components of health care value. And we assume that patients share that perspective. But, it seems, they don’t. When the Utah survey asked patients to identify key characteristics of high-value health care, a plurality (45%) chose “My Out-of-Pocket Costs Are Affordable,” and only 32% chose “My Health Improves.” (In fact, on patients’ list of key value characteristics, “My Health Improves” was slightly below “Staff Are Friendly and Helpful.”) Given the chance to select the five most important value characteristics, 90% of patients chose combinations different from any combination chosen by physicians. In general, cost and service were far more important in determining value for patients than for physicians.

Frankly, I was stunned by the degree of this misalignment between patients and physicians (and, by extension, the care delivery organizations the doctors work for). This disconnect alone could account for a substantial portion of the Sisyphean lack of progress we’ve seen. But there are plenty of others. Notably, the Value survey found a striking lack of consensus on who had responsibility for ensuring that health care embodies the desired high-value characteristics. Moreover, the survey’s respondents generally displayed limited understanding of how the health care system works more than a step or two beyond their direct experience. This led to responses at odds with reality — for example, only 4% of patients and physicians recognize that an employer’s choice of health plan affects out-of-pocket costs.

Both of these kinds of misalignment — regarding the relative importance of outcome, cost, service, and quality, and who is responsible for achieving specific value characteristics — demonstrate the core problem: Stakeholders have not communicated with each other effectively, at the macro and micro levels, on what value means to them. I have two thoughts on how to start the process of getting communications and information flowing.

At the micro level, we should leverage the growing power of physician- and hospital-review systems to gather more (and more-sophisticated) information on what is most valued by individual health care consumers. Our system alone collects more than 3,500 patient comments a week. Now we need to apply our growing computational capacities to deeply mine that data both within and among systems to create an enhanced patient experience that is informed by how they define value. And business leaders should expand their companies’ efforts to track and analyze — and educate their employees about — the multiple dimensions of value in the health benefit plans they offer.

At the macro level — national, regional, and inter-institutional — major organizations should step up to convene initial rounds of stakeholder dialogues. Academic medical centers (AMCs) such as University of Utah Health are well positioned to be conveners. (The Utah Value Forum this month brought together regional stakeholders to address the challenges we all face.) AMCs are also uniquely qualified to undertake rigorous research to better understand the misalignments and misunderstandings found in studies like the Value survey. In fact, more than simply being capable, I think the public service missions of AMCs virtually obligate them to be leaders in this essential effort.

But they are not obligated to lead alone, nor would their solo leadership be compelling enough to bring all stakeholders to the table. We need corporate health benefit plans, for-profit health systems, and insurers — at a minimum — to help lead this effort.

If Messrs. Bezos, Buffett, and Dimon really want to drive major change in the U.S. health care delivery system, they should help convene value-focused dialogues, providing the kind of political and economic cover necessary to bring stakeholder groups into these conversations. And they shouldn’t stop there: They’ll have to remind everyone that these conversations aren’t only about cost containment — that “value” means more than just what we pay. (Or, as Buffett put it in one of his famous chairman’s letters, “Price is what you pay; value is what you get.”)

They should partner with providers, hospitals, and health systems to develop more-effective provider/hospital review systems and other methods of enhancing communication among parties in the care delivery process. They should seed pilot projects aimed at bridging the gaps in patients’, physicians’, and employers’ definitions of value. And being the smart, creative, bold people they are, they should help guide all stakeholders through the difficult compromises necessary to create a collective vision of a high-quality, patient-focused, cost-effective health care system.

That would truly be disruptive.