In Providers’ Words: What’s Working and What’s Not in Value-Based Care Today

Earlier this month, Premier hosted a panel on value-based care (VBC), with providers from across the healthcare continuum discussing its merits and pitfalls.

In attendance were members of Congress and their staffers to hear how precisely VBC has been effective and policy changes needed to continue its forward progress.

One message came through above all others: VBC has unshackled these providers from the inherent constraints and archaic rules in fee-for-service (FFS) and allowed them to develop innovative models that recenter around the patient.

Alternative payment models (APMs) have also enabled measurable improvements in quality and cost – but providers need legislative help to keep the momentum up.

Here is what’s working and what’s not in VBC today – and what can be done about it.

What’s Working:

High-Value Networks That Align Financial Incentives with Patient Outcomes

“Having that network, data and support has changed the way we care for our patients. We’re out of our silo now, looking at skilled nursing facilities (SNFs), hospitals, medication cost and service to the patient in different ways. We spend time talking to patients on an individual basis; they’re our VIPs.”
- Sarah Mullins, MD, partner of Stoney Batter Family Medicine and medical director of Aledade Health, on how the network approach has enabled its 800+ independent practices to better serve and invest in patients.

“We worked with SNFs in developing high-performance networks and having them commit to high quality measures. It’s allowed us to create a preferred network that dramatically reduces the length of stay.”
- Richard Shuman, MD, CEO of Baycare Health Partners, a four-hospital system in western Massachusetts that covers 90,000 lives in commercial value-based care.

“When a patient enters into our network, they are treated according to evidence-based algorithms. Through these algorithms, patients receive evidence-based care that reduces their risk.”
- Dr. Patel on how the Integrated Health Partners CIN has been able to standardize care across 270,000 lives.

Payment Flexibility to Deliver Modern-Day Care

“Our no-show rates for behavioral health were over 30 percent, and now it’s less than 10 percent. The pandemic has spurred higher instances of depression, anxiety and substance use, all of which we’ve addressed via telehealth. We’ve decreased disparities in care.”
- Dr. Patel on how the Integrated Health Partners CIN has decreased inequities in care, particularly around transportation, by using telehealth during the pandemic – noting providers were only really incentivized to leverage this medium when the Centers for Medicare and Medicaid Services (CMS) issued telehealth waivers last spring.

Dr. Shuman listed upwards of 20 innovations enabled by alternative payment models, both before and during COVID-19 public health emergency, including:

• Stratifying populations by medical conditions.
• Conducting a cultural and linguistic needs assessment.
• Delivering more than 1,000 meals and creating food banks in health centers.
• Providing face masks, room dividers, air mattresses, cleaning supplies, thermometers and pulse oximeters.

“The model allowed us to do that,” he stated clearly. “FFS would never allow us to do it.”

Care Coordination

“We’ve embedded care managers into almost all of our 175 practices. We manage some of the sickest patients in those practices, and we’ve seen a significant reduction in total cost of care and net promoter scores over 80.”
- Dr. Shuman on how integrating care management into physician practices drove results that Baycare could “never do in standard models.”

“It’s allowed for expansion of care that’s out of the box.”
-Dr. Mullins with Aledade echoed how the implementation of care management enables her practice to cover work beyond the exam room, to the point that a patient who was in the hospital and was recommended heart surgery called to ask her opinion.

Read more: Premier experts on how to calculate the elusive ROI for care management.

What’s Not Working

Data: Panelists say they need more cooperation and coordination with their payers. “[Payers] hold all the data; we’re duplicating efforts in many instances,” said Dr. Patel. “We have little visibility into historical total cost of care, so we’re entering into risk-based arrangements without a true understanding.”

• What CMS can do about it: Continue speeding access to claims data with common formatting. Consistent definitions reduce the challenges of leveraging the data in a comparative manner.

Specialist incentives: Panelists agree that current APMs have not adequately incentivized specialists, who are still measured by a FFS yardstick, to move to value-based medicine. From the perspective of Dr. Mullins at Aledade, primary care practices are small businesses working on razor-thin margins, often barely making payroll, and specialist costs are out of control. In total cost of care models such as accountable care organizations (ACOs), the difficulty in engaging specialists and the costs of their services can significantly harm the potential for the ACO to achieve shared savings.

Dr. Shuman echoed that in observing, “It’s hard to create systems that incentivize not just primary care physicians.”

• What Congress and the administration can do about it: Restructure incentives to better incorporate specialists into existing models.

Reliable Payment Systems to Uphold VBC Infrastructures: “We always talk about the money to build something new, but we rarely talk about the money to maintain it,” Dr. Shuman said. “Often, we hear from payers and others, ‘Well, you built it, we don’t need to continue to support it anymore.’ No, we need that continued support to move the dial.”

• What Congress can do about it: Continue to incent the movement to value by extending MACRA bonuses which are set to expire in 2022. Additionally, Congress should emphasize APMs and total cost of care models that measurably return shared savings to providers, such as MSSP and the Next Generation ACO model, which has successfully organized care in local communities but is set to expire at the end of this year without another available full risk option. Providers in Premier’s Population Health Management Collaborative continue to prove the utility of such programs by regularly generating savings for Medicare and qualifying for shared savings, outpacing national averages.

Benchmarks: The current benchmarking approach in ACO models creates a race to the bottom whereby providers must lower costs year over year to remain successful. For those who have made significant gains over past years, it becomes increasingly difficult to meet new benchmarks – made only possible by disrupting their own efforts.

“As we innovate, our patients cost less,” Dr. Mullins said. “Unfortunately, our patients are included in that benchmark, so after years, we’re compared to ourselves. Then, we’re no longer a disparate group from those not innovating.”

• What CMS can do about it: New benchmark approaches should consider removing a group’s own patients and consider how to avoid penalizing those in low-cost regions or providers who are dominant in the market. Premier has long advocated for the Rural ACO Improvement Act to accommodate these improvements.

Incentives for Vulnerable Providers: VBC programs, advance payment bonuses and MIPS don’t apply to safety net hospitals, shared Lynn Barr, Caravan Health founder and executive chairwoman. Because they operate at costs, vulnerable providers, including safety net hospitals and rural providers, lack the ability to move to models founded on shared savings.

• What Congress can do about it: Work with the administration to determine approaches for moving vulnerable providers to a budget rather than models focused on achieving discounts. Vulnerable providers, such as safety net hospitals and rural providers, operate at cost with minimal margins. The goal of models to achieve savings can be in conflict with providers remaining whole.

Providers are clearly the ones leading the charge forward in value-based care – but they need help from Congress to incent a clear path forward.

“None of [our successes] would be possible without the APM,” said Dr. Shuman of Baycare. “[Legislators’] support of these models has truly saved lives. Continue to give us the financial flexibility, and we’ll truly be able to make a difference in our community.”

Leveraging more than a decade of experience running the nation’s largest population health collaboratives, Premier recently laid out an approach for the Center for Medicare & Medicaid Innovation to advance value-based care. Check it out here.

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