Back to previous page


We're working with Montana providers to help deliver high-quality and high-value care.

Let's imagine a health care patient.

We'll call her Nancy. She’s 42 years old, married, has a degree in accounting, and works full time at an engineering firm. Nancy loves to hike, and she's already climbed six of the tallest peaks in Montana. She's also practical. She wears tennis shoes instead of hiking boots, because her dad taught her what she calls ‘a healthy disdain’ for marketing.

Lately, though, Nancy hasn’t been hiking because of escalating back pain. On her doctor's advice, Nancy is planning to have back surgery soon.

Nancy is not alone in this decision. Back pain is the most common type of chronic pain in the U.S. Each year, hundreds of thousands go under the knife in search of relief. That number has grown steadily over the last several decades — despite proof that surgery is not the best treatment for most people suffering from back pain.

It's a widespread issue in health care. According to the National Academy of Medicine, about a third of what the U.S. spends on health care pays for unnecessary medical services and other kinds of waste .

The human costs — in pain, follow-up surgeries, lost work and family time, and sometimes even death — are huge. Dr. Monica Berner, Plan President for Blue Cross and Blue Shield of Montana (BCBSMT), contends that any health care that isn't needed is harmful.

"It's harmful to the patient's convenience," Berner says. "It's harmful to their wallet. It's harmful to their employer. It's harmful to our economy. And it's frequently harmful to their health."

And while stakeholders have struggled to solve the problems of unnecessary care and high costs, nearly everyone agrees on one major cause for both: Our health care system provides financial rewards for delivering more care, whether it's needed or not. As a result, health care has grown around services that are profitable instead of around services that deliver positive health outcomes.

According to Patty Estes, Senior Director of Network and Innovation Strategy at BCBSMT, the solution must go beyond negotiating lower prices from health care providers.

"A lower price on something you don’t need isn’t really a lower price. If you get a dollar off a sandwich and then throw it in the garbage, it still wasn’t a very good use of your money," Estes says. "To truly fix our health care system, we need to stop paying for quantity and start paying for quality. That means reorganizing care around the delivery of health, rather than health care."

That's one reason BCBSMT started a value-based care initiative nearly 10 years ago. Programs under this initiative give providers incentives to follow evidence-based guidelines.

For example, one quality metric discourages providers from ordering imaging — such as X-rays and MRIs — within 28 days after a patient's lower back pain starts. For most people, the pain subsides without intervention. A study in the Journal of Occupational and Environmental Medicine found that patients were eight times more likely to get back surgery if they got scanned in the first month — and didn’t recover any faster.

Avoiding unnecessary services is just one piece of the value-based care equation. Value-based care also gives provider resources to expand office hours, shorten wait times, spend more time with patients and reach out to make sure patients have received recommended preventive screenings.

According to Berner, one of the reasons value-based care is so successful is that it isn't focused only on costs.

“Value-based care, first and foremost, is about changing processes to improve patient experience and enable better health outcomes,” she says. “It just so happens that delivering high-quality care tends to reduce some of the biggest drivers of cost in health care — like hospitalizations, ER visits, duplicate services and medical conditions that spiral out of control.”

After 10 years of studying the program, BCBSMT has seen a $28 per-member-per month reduction in costs for participants.

“The most satisfying part of those savings,” Berner says, “is that they correspond with better health for our members.”

Health care providers also report greater satisfaction from participation in value-based care initiatives. Glacier Medical Associates (GMA) in Kalispell has been partnering with BCBSMT on value-based care since 2013. GMA contends the program helps improve the quality of care for its patients and provides the financial resources to make necessary changes.

“The value-based care model has been a crucial part of Glacier Medical’s success,” says Bri Wallace, Quality Programs Analyst for Glacier Medical Associates. “Our patients are receiving personalized team care that has improved the overall health of our patient population and Glacier Medical has been able to remain a privately owned practice because of the financial support of the value-based programs.”

The next step for BCBSMT is integrating these value-based concepts completely into its reimbursement contracts with hospitals, so compensation is fully tied to quality and efficiency.

“We think it’s rare that a health care provider intentionally delivers unnecessary care for financial gain,” Estes says. “But the current system gives all these little nudges, and the result is the same. We are working to take those nudges away and point them toward quality. Providers are receptive. They understand the need to change. They just need help getting there.”

For patients like Nancy, progress can’t come soon enough. Today, she must choose between two paths.

One path comes with an uncertain promise of quick relief from agonizing pain. It's offset by the risk of serious complications and the financial toll on her own budget and the health care system.

The other path will include weeks of physical therapy, changes to her workspace, and, ironically, a pair of specialized shoes. And while this option has mountains of evidence to support it — it has an entire system working against it.

Thankfully, as initiatives like the BCBSMT value-based care program build momentum, there is reason for hope that change is coming.