Industry Perspectives: Value-Based Care

The last few years have reshaped most industries, but perhaps none more than healthcare. The COVID-19 pandemic accelerated the need for healthcare systems to restructure themselves and one of the most important components of that restructuring is the transition into value-based care (VBC). We asked thought leaders in the healthcare world to share their insights around value-based care and dig into the potential challenges that may arise as a result of this transition.  

Amy Berk, MSN, RN, Director Population Health, Microsoft

What specific CMS/payer policies or reimbursement barriers remain that are delaying the transition to value-based care models?

The complexity of alternative-payment models (APM) models, associated cost-modeling, and the ever-evolving value-based care (VBC) policies and regulatory initiatives prohibit many providers from advancing their VBC initiatives. More than policy and regulation, it is the lack of investment, resources and infrastructure that is prohibiting value-based care arrangements, e.g., interoperability. as well as provider adoption and adaption to value-based payment models.  Regulations are moving so fast that providers are often not able to keep up.

Where is value-based care working to address improved health, access, and affordability? Are there new practice models that are adapting to value-based payments more easily than traditional, established practices?

Value-based care is working to address all of these areas. At its core, the goal of VBC is to improve health outcomes and reduce cost of care. As for access and affordability, policies and measures that pertain to telehealth are now prominent as telehealth has evolved its footprint to improve access to care. The affordability proposition is much more complex, but moving care into the home, and more robust comprehensive care management programs are two examples of how value-based care is addressing affordability. When we think about health equity, population health predicates the need to identify targeted and vulnerable populations to address gaps in care, social determinants of health (SDoH) needs, and overall improvement of health and financial outcomes.

Which non-clinical factors (i.e., patient preference, social determinants of health, sexual orientation, and gender identity, cultural or religious perspectives) should be incorporated into value-based care programs when considering “value”?

Currently SDoH is making an impact in value-based programs and rightfully so; the goal is now to ensure measurement of impact on populations. Other attributes like sexual orientation, gender identify, religious and cultural beliefs are all important and definitely have an impact on how one thinks about their health. but also how providers must accommodate these needs in how they deliver care.

What actions can we take to expand value-based care into ancillary sites (e.g., post-acute care, dental, behavioral health, public health) in the global health ecosystem?

This is already starting to happen. CMS’ACO Reach Model accounts for VBC reach into communities and the significance of SDoH on outcomes. To expand into the other domains, there has to be more continuity with these entities as partners in the same light as “community partners”. They need to recognize that each of these entities have an impact on “whole-person care,” and ensure that there is a seamless relationship with these providers when appropriate. Expanding these relationships is very much dependent on both technology infrastructure (interoperability to facilitate data exchange and more proliferatively care coordination) and the data itself as a commodity to gain clinical insights and deliver “whole-person care.”

How will the digitization of health aid the transition to value-based care?

Digitalization of health will transform and optimize value-based care. As noted, the technical infrastructure is so important because it not only provides a platform for the data, but it allows the data to be harnessed for clinical, operational and financial insights.  As another layer, interoperability is the engine that enables the exchange of data to facilitate care coordination and value-based care arrangements overall. Furthermore, the integration of data from various sources, including SDoH and Patient Monitoring Data coupled with interoperability, presents an opportunity to deliver more personalized and whole-person care.

The Centers for Medicare and Medicaid Services are planning to adopt digital quality measurement or “dQM” quality reporting programs by 2025. How does the transition to dQM impact the industry’s gradual move away from fee-for-service to value-based reimbursement?

The provision of digital quality measurement enables more real-time reporting and allows providers to focus on closing gaps of care more quickly. Overall, dQM provides standardized, consistent data definitions that allow for increased rigor in data validation and promote system-wide adoption. The dQMS are easier to consume, offer consistent measure calculation to reduce quality program burden. and provide timely and actionable interventions at the point of care.

 

George Mathew, MD, Chief Medical Officer, Dedalus

What specific CMS/payer policies or reimbursement barriers remain that are delaying the transition to value-based care models?

CMS and payers hope providers take on as much financial risk as possible. However, many providers are not able to take on that much financial risk because they still make the majority of their revenue from Fee for Service (FFS).    

Many payers are open to transitioning to value-based care. They have superior data sets, robust computing power, and better financial positions, which allows them to negotiate both capitated and value-based agreements. 

Providers have to work well within capitated budgets for value-based care to be successful. Though they may be able to control some factors, ultimately if costs exceed revenues, they will be operating at a loss—which is why many are hesitant to sign up, unless they can build in some safety buffers for performance. By obtaining more working capital from payers and CMS it is possible to ensure a smoother transition.

Where is value-based care working to address improved health, access, and affordability? Are there new practice models that are adapting to value-based payments more easily than traditional, established practices?

There are reports that indicate providers are starting to incorporate credit scores, but this has been mostly the domain of marketing as a way to pre-assess and pre-qualify consumers for potential elective procedures, or supplement engagement strategies.

Which non-clinical factors (i.e., patient preference, social determinants of health, sexual orientation, and gender identity, cultural or religious perspectives) should be incorporated into value-based care programs when considering “value”?

Ideally all of the non-clinical factors should be incorporated into a value-based care program. These factors not only customize the care for the consumer but can also lead to better adherence and compliance.  

Per the World Health Organization (WHO), this also includes: Income and social protection, education, unemployment and job insecurity, working life conditions, food insecurity, housing, basic amenities and the environment, early childhood development, social inclusion and non-discrimination, structural conflict and access to affordable health services of decent quality.

This in addition to individual preference, SDoH, sexual orientation and gender identity, cultural or religious perspectives, which should be built into the value-based programs and used to evaluate success.

What actions can we take to expand value-based care into ancillary sites (e.g., post-acute care, dental, behavioral health, public health) in the global health ecosystem?

There is a clear need to expand data collection and data standardization to non-hospital ancillary sites, including the home, and to calculate necessary budget for supporting global capitation rates.

How will the digitization of health aid the transition to value-based care?

When health is truly digitized, specific components and processes are virtualized, automated, and less expensive which opens the door to new virtual (in-person and telemedicine) healthcare products services that can meet multiple price points for more patients and allow providers and payers to offer a portfolio of patient care options.

The Centers for Medicare and Medicaid Services are planning to adopt digital quality measurement or “dQM” quality reporting programs by 2025. How does the transition to dQM impact the industry’s gradual move away from fee-for-service to value-based reimbursement?

dQM should facilitate data capture and metric improvement. Data capture for metrics is typically labor intensive and time-lagged (claims can take as long as three months or more to be verified), leading to delays in determining whether the Quality Measures are linked to actual success. dQM should automate the data capture, reducing the work needed, and allowing for close to real-time data.  

If the dQM’s can be linked to showing improvements quickly in overall community and individual health, it should accelerate the transition to value-based reimbursement.