What You Should Know:

– Independent research reveals family physicians with 75% revenue derived from value-based payment models decrease burnout symptoms, according to a new study from Elation Health, and American Academy of Family Physicians (AAFP) Innovation Lab.

– The goal of the study, conducted by surveying 10 primary care practices of varying sizes, was to identify specific barriers and innovations required for mainstream adoption of value-based payment (VBP) models and their relationship to physician burnout. 

Key Findings

Key findings from the study illustrate both the promise and the challenges involved with VBP models. The following themes emerged:

– Infrastructure: A significant factor in burnout is the amount of work to be done related to the resources available to efficiently do the work. The study uncovered a threshold of financial investment needed to support adequate infrastructure to enable success in VBP and reduce the associated risk of burnout. In larger practices or in practices with network affiliations, economies of scale made VBP administration more manageable. Beyond human resources, the adoption of technical solutions supported operational efficiencies, helping contain operating expenses and enabling clinical and financial success. 

– Capitation Factors: Practices with capitated models, or risk-adjusted, per-person payment models, experienced less burnout than those with payment models designed around retrospective “bonus” payments. The study also replicated findings that higher capitation rates combined with the greater percent of total revenue from capitation can most effectively relieve physician burnout. 

– Quality Measures: The effort required to identify, deliver, report, and get paid for a set of payer-driven quality measures is proportionally high for the majority of practices, regardless of size. The study showed that practices with fewer payer contracts had less burnout, given its link to fewer or simpler workflows to achieve success.

– Payer-Practice Contract Quality and Innovation: The most successful practices in the study benefited from innovative and savvy contract design between the practice and the health plan, sometimes involving partner health systems. Practice leaders who worked closely with payer organizations to design contracts around the power of primary care to influence downstream utilization patterns and costs of care of an attributed population realized better financial outcomes for the practice, reported a better experience of delivering care, and enjoyed the least amount of burnout. 

“Value-based care holds much promise by creating supportive collaborations between patient and physician, improving quality of care, and reducing healthcare spending,” said Dr. Steven Waldren, MD, MS, chief medical informatics officer at AAFP. “In this second study with Elation Health, we found it critical to further explore the challenges family physicians face as they work to transition to value-based payment models and to understand which innovations help them break through these barriers without putting themselves at risk of burnout.”

What You Should Know: 

– Ventricle Health – a new national, virtual cardiology clinical reimagining cardiac care delivery – raises $8M in seed funding led by RA Capital and Waterline Ventures. 

– This company will used the seed funding to expand Ventricle Health’s heart failure management therapeutic model in collaboration with value-based care provider groups and payers, which can reduce the overall average annual cost of heart failure care by at least 30-50%. 

Virtual Cardiology Clinical Reimagining Cardiac Care Delivery

1 in 4 admitted heart failure patients are readmitted to the hospital within 30 days of discharge. But, only 22% of eligible heart failure patients are on guideline-recommended drugs – stressing the importance of a reimagined care model for cardiology. In addition, Access challenges to get to a cardiologist in a timely manner after hospital discharges only exacerbates the problem of heart failure-related re-admissions. Today, the average wait time to secure a cardiology appointment in the U.S. is 26 days – time that can make all the difference in the outcomes and ultimate costs of caring for a heart failure patient.

Founded in 2021 by top heart failure cardiologist, Dr. Dan Bensimhon, Ventricle Health’s care model is anchored around well-established guideline-directed medical therapy (GDMT) pathways. They provide patients access to cardiology care appointments from their home in as little as three days. Ventricle Health’s home-based and virtually enabled care model can reduce the overall average annual cost of heart failure care by at least 30-50%.

The Company is operational and delivering high-impact virtual and home-based clinical services in support of Accountable Care Organizations (ACOs), primary care practices and their payer partners in the Mid-Atlantic, Texas, Ohio and Florida, with more markets to be announced in the near future.

In theory, electronic health records (EHRs) have the potential to transform the healthcare landscape. They were expected to provide a digital hub that would enable seamless communication and information sharing between providers, boost efficiency, improve the quality of care, and foster optimal patient and clinician experiences. 

The reality, unfortunately, has not matched the possibilities. 

While well-intentioned, the Federal Government’s 2011 Meaningful Use Mandate program—to incentivize physician practices to adopt EHRs—did not specify detailed standards for EHR systems. The result was a fragmented landscape of multiple vendors offering poorly designed EHRs that met the certification requirements at the expense of the provider and patient experience. 

And because early EHRs lacked user-centric design, many unintended consequences followed. One of the biggest issues and strongest dissatisfiers for providers has become the amount of time they spend using the EHR system during patient visits versus interacting with the patient face-to-face.  

When EHRs were being widely adopted in the 2010s, technology was also entering a new phase with mobile devices and cell phones—triggering a permanent shift toward more user-friendly and always-connected devices. The contrast between the user experiences of the siloed EHRs and the modern mobile apps could not have been more striking. 

In addition, the “data dump” nature of these systems makes it difficult for physicians and other caregivers to parse out meaningful, actionable information regarding patients’ health. And exchanging data across practices or other systems such as hospitals and labs is manual and time-consuming (requiring faxes and phone calls), or expensive (often requiring custom point-to-point interface development).  

Ultimately, the patient-provider relationship suffers, as does the quality of care. Implementing these EHRs is viewed by many as a box-checked, not a medical asset—and rightly so. 

With value-based care contracting becoming increasingly inescapable, EHRs need to do better. In fact, value-based care may finally drive everyone to demand that EHRs deliver on their original promise.  

Value-based care is centered on the premise that tying reimbursement to better patient outcomes can improve patient health and drive down costs of care. However, quality and value are very difficult to measure, much less create.  

Payers recognize this and are empowering providers and practices to take on that risk. This ultimately sets providers up to have more ownership and accountability in the care delivery decisions and to operate at the high end of their license. 

To do this effectively, practices and providers need—and should demand— a customizable, smart, capable and efficient EHR that supports them in this paradigm shift toward enhancing the quality of care and improving patient outcomes. Here’s how: 

Intelligence 

While the general premise of value-based care is consistent, there are numerous models with different mandates. Each health specialty will have its own quality measures too.  

Take nephrology, for example. The U.S. Department of Health and Human Services has established several lofty goals to move more people to home dialysis, increase organs available for transplant, and reduce the number of Americans developing kidney failure in the first place.   

There is a multitude of value-based payment models and partners focused on achieving these goals, and nephrology practices need an EHR that specifically supports what’s applicable to them. This can happen at an individual and population level.  

An EHR oriented to value-based care should discern and identify population trends and risk factors, using multiple data sources, empowering providers to take proactive action that heads off more serious health issues. For instance, a robust EHR may identify a population that is driving up costs because there are few healthcare options nearby other than the emergency department or have a high prevalence of diabetes because they reside in a food desert.  

Though it isn’t widely expected today, the ability of an EHR to recognize trends and prompt intervention is critical to value-based care. Ultimately, success in value-based care requires providers to change behavior to deliver care through the right intervention, to the right patient at the right time.

Finally, as providers come to participate in multiple value-based care agreements, an intelligent EHR must clearly identify which patients are attributed to which value-based care program, and their associated health and financial metrics.  

Integration 

Another pillar of value-based care is that it enables “whole-person care.” So, while an effective EHR should support the nuances of a specialty, it should also seamlessly collaborate and communicate with other providers. Eliminating duplicate tests and exams, as EHRs were intended to do, and preventing negative treatment interactions, requires visibility of all patient activity.  

Nephrologists come to function as principal care providers for those with end-stage kidney disease (ESKD). 

They need to be acutely aware of details gathered from outside their office, such as hospital visits, dramatic changes in blood pressure, medication changes, and more. And these details cannot simply be displayed during the patient’s next nephrology appointment, the EHR must proactively alert the provider so action can be taken immediately.   

Efficiency 

A prime promise of EHRs is efficiency—reduced paperwork, better patient engagement, and streamlined staff workflows. At the same time, good value-based care demands more time. So, every minute of administrative work saved is an extra minute the care team can spend on patient care and service.  

Value-based care will drive providers to expect their EHRs to deliver on their time-saving promise in ways like never before.  

EHRs of the value-based care era automate standard processes, such as assigning a staff member to follow up with the patient in a timely fashion and enable seamless visibility of the variety and status of extended care patients receive outside the in-office appointment.  

EHRs also have a role in analyzing the quality outcomes of patient interventions. Only by doing this is it possible for a provider to reasonably measure the effectiveness of each initiative undertaken to both improve patient health and reduce costs.  

Why Now? 

EHRs should be a net benefit to the provider, the practice, outside practices and the patient. They should be more than just a tool and serve as a digital partner enabling improved patient care and more satisfied employees operating at the top of their license.  

Most providers likely don’t feel that way about their EHR today, which can understandably create reluctance to invest more time and money into adopting a new system.  

However, with the quickly rising prevalence of value-based care agreements, it’s important that practices consider if they have the technical infrastructure to take that leap.  

Clinical charting and billing are table stakes. Practices need to critically assess whether their EHRs have robust interoperability, advanced data analytics capabilities, and strong patient engagement features that deliver on the keys to success in value-based care. And because selecting and deploying an EHR can take 12-18 months, moving forward now is likely the best time. 

About Sam Gopal 

Sam Gopal serves as President for Acumen Epic Connect, a division of Interwell Health, a leading kidney care management company. Gopal has more than 25 years of experience in management consulting, strategy, and product management, and leads the nation’s best-in-class EHR for nephrology practices.  Sam has specific experience launching and scaling startup service lines inside of large enterprise organizations, which he brings to bear for Acumen’s transition to Acumen Epic Connect and Value-Based Care offerings. Sam holds a bachelor’s degree in mechanical engineering from the Indian Institute of Technology, a master’s degree in industrial engineering from Purdue University and a master’s degree in management from Harvard University Extension School.

What You Should Know: 

– Veradigm Inc., a provider of healthcare data and technology solutions and On Belay Health Solutions announced a strategic collaboration to support primary care providers in improving patients’ health outcomes while strengthening their practices’ financial foundation.

– The shift from a fee-for-service healthcare delivery model to a value-based care model has significantly changed the way healthcare is delivered and reimbursed in the United States. Veradigm’s innovative solutions help to promote value-based care initiatives for healthcare providers and most importantly, the patients they serve. Through On Belay Health Solutions, Veradigm Network’s primary care physicians (PCP’s) are poised to improve patient outcomes along with their care team experience.

– On Belay Health Solutions supports independent primary care physicians in their quest to access meaningful value-based contracts and provides the clinical and operational support necessary to succeed and maintain their independence.

While the need to address social determinants of health (SDOH) is definitely not new, 2023 marks the first year SDOH is codified into national and statewide value-based payment program mandates. These mandates are designed to hold Managed Care Organizations (MCOs) and Accountable Care Organizations (ACOs) accountable. While the rollout of SDOH code sets across our healthcare ecosystem is one phase, alone it’s not enough. The next phases are even more critical: codes must be collected, used, reviewed, and acted upon within value-based payment programs to ensure patients realize the benefits of a more inclusive and accessible healthcare system. 

The newest value-based payment program purposely designed to address SDOH is the ACO Realizing Equity, Access, and Community Health (ACO REACH) model, launched by the Centers for Medicare & Medicaid Services (CMS). ACO REACH participants are required to develop a health equity plan to identify underserved patients within their population and implement initiatives to measurably reduce health disparities. While this is not the only requirement, it will challenge ACO REACH participants to collect complete and accurate SDOH data. 

For health plans, they’ll need to sharpen their data collection processes to encompass critical non-medical information. Traditional methods of data collection, such as complex care case management assessments, are no longer sufficient. Payers must have access to and include publicly available data collection aimed to offer a more comprehensive view of a member’s health and social circumstances to comply with CMS guidance. The data payers collect must also be consistent and precise across populations. 

Without standards-based data collection, coding, and uniform information sharing of SDOH data between healthcare providers, health plans (including MCOs) and community-based organizations, it will be extremely difficult — if not impossible — to effectively improve health outcomes.  

States like Massachusetts, New York and Oregon, are leading the way in addressing SDOH data use in value-based payment programs for Medicaid beneficiaries. These early adopters are highlighting how the collection and use of SDOH data leads to better and more equitable health outcomes and the industry is watching. We’ll all learn from how each state addresses the challenges of collecting complete, accurate, standards-based SDOH data, as well as how that information is shared with providers and community-based organizations. With insights from these states, the industry will be better equipped to develop consistent approaches that lead to improved health outcomes and increased health equity. 

While underutilized, one standards-based solution to the challenge of quantifying social, economic, and environmental factors known to affect health and health-related outcomes already exists. In 2021, the CMS Office of Minority Health published data on the use of ICD-10-CM Z codes. Since 2016, Z codes have been available to capture SDOH data at the point of care delivery. Providers submitting claims using ICD-10-CM Z codes to document SDOH have been steadily increasing, from less than 946,000 claims in 2016 to more than 1.2 million in 2019, according to the CMS report. Though that may seem like a large number, as a proportion of the 33.1 million people enrolled in Medicare that year, less than 2% had claims that incorporated Z codes. 

Our current Z code submission rate, while limited, is a great step forward to capture standards-based SDOH data at the point of care for our nation’s most at-risk people; however, more widespread adoption is required to comply with the SDOH requirements mandated in CMS and state value-based payment programs. Look to Standards Development Organizations (SDOs) like the Council for Affordable Quality Healthcare (CAQH) to drive this adoption by adjusting data collection operating rules that define key infrastructure and data content requirements.  One example of this work can be standardizing the submission of ICD-10-CM Z codes on claim transactions to support SDOH data capture at the point of care.  Millions of these claim transactions are already being passed between payers and providers every day.

Integrating SDOH data into value-based payment models also comes with some challenges – beyond figuring out a standardized approach that works. Data privacy and security concerns are paramount, with additional information being collected on individuals. Additionally, there is an abundance of interoperability issues to be addressed at the health IT system level to ensure collaboration and in order to guarantee the seamless exchange of data for maximum outcomes.

As we look ahead, standards-based SDOH data collection — from claims, publicly available information, data from care assessments, integration with clinical notes in electronic medical records, and more — will be essential to remove the barriers to care that value-based payment programs were designed to eliminate. 

We all aim to build a healthcare system that treats the root cause of health disparities, ultimately leading to healthier communities and better health outcomes for everyone. As leading ACOs and MCOs demonstrate the power of harnessing SDOH information to create more equitable and effective care models, the transformative potential of SDOH data promises to reshape the entire healthcare landscape for all. 

About Michael Pattwell

Michael Pattwell is the principal business advisor at Edifecs, a software provider that enables payers and providers to maximize the performance of their value-based contracts and offerings. Michael has more than 30 years’ of experience in health care and currently chairs national value-based payment workgroups at WEDI, CAQH and DaVinci. An author of several articles on our national transition to a value-based payment model and our industry focus on population health management.

Walgreens, Pearl Health Partner to Expand Value-Based Care Delivery

What You Should Know: 

– Walgreens and Pearl Health, a provider enablement company has announced a strategic partnership to accelerate the expansion of value-based care in collaboration with community-based primary care physicians.

– Pearl Health offers technology and insight solutions that empower clinical teams to provide holistic, personalized treatment necessary for value-based, quality-focused care. 

– As part of the strategic partnership, Walgreens will provide complementary services, including prescription fulfillment, medication adherence, immunizations, care gap closure and diagnostic testing. In addition, Walgreens will also work with providers to help patients discharged from the hospital transition to home.

Walgreens Continued Investment in Value-Based Care

The announcement marks Walgreens’ continued investment in value-based care, recently being the company’s majority investment in VillageMD, a national leader in primary, multispecialty and urgent care. A technology-enabling partnership with Pearl Health provides an additional, complementary value-based delivery channel that will allow Walgreens to reach more regions and patients and offer an even broader set of solutions to providers and health systems.

“Walgreens is committed to being the partner of choice for providers and health systems looking to transition quickly and effectively to value-based care and improve outcomes in the communities they serve,” said John Driscoll, executive vice president and president, U.S. Healthcare, Walgreens Boots Alliance. “Our partnership with Pearl Health allows us to reach more communities faster and enable comprehensive, affordable care that improves long-term health outcomes and fosters healthier communities.”

Poorly managed chronic conditions—most of which are related to lifestyle—cost employers $36.4 billion each year in the form of absenteeism and poor productivity. Add in coverage-related and other costs, and that number skyrockets to $575 billion. Coverage costs alone have increased by 47% over the previous ten years. 

Research shows that at-risk employees can benefit from care management programs that help them better maintain their chronic conditions, while employers benefit from lower costs and improved productivity. Although many TPAs and ASOs offer a care management program, those programs are often part of a larger bundled solution. And therein lies a problem: It is virtually impossible to measure results when the program is bundled—regardless of what these organizations claim.

The challenge is that TPAs and ASOs typically use care management programs as loss leaders within the bundled solution, leveraging network discounts to drive returns. Simply put, they have no skin in the game, and no incentive to deliver results. This is why employers are increasingly turning to stand-alone care management programs.

Why stand-alone is better

Companies that offer carved-out solutions are able to isolate expenses, including coordination of services and the management of high-risk employees. They can also track outcomes down to the most minute elements in the program, giving them the ability to perform a highly detailed analysis of a program’s effectiveness. This is not possible with a bundled solution.

In addition to better outcome measurements and transparency, stand-alone programs provide more targeted engagement strategies based on each employee’s unique health needs, while bundled solutions often fall into a one-size-fits-all model.

When it comes to payment structures, stand-alone programs come out on top here too. In bundled programs, savings are wrapped into network-negotiated rates or benefit designs. Conversely, stand-alone programs have payment models based on outcomes and results.

Bundled care management solutions often measure results based on the number of touches while stand-alone solutions measure results based on engagement and outcomes.

What to look for in a stand-alone care management program

When choosing a carved-out program, employers should first and foremost look for a partner that takes a member-centric approach by tailoring the program to align with the employer’s goals and unique employee population. This requires the identification of high-risk employees using retrospective as well as prospective analytics. Outreach to these employees needs to be proactive and ongoing and not dependent on the employee taking the first action.

To achieve optimal results, care management programs must address lifestyle changes, which can only come through targeted education, customized support, and ongoing engagement focused on the employee. Cookie-cutter programs don’t work well as they don’t create a personalized employee experience.

Next, employers should choose a partner that can break out all program costs from any other service provided, not just using a percentage of the broader bundled costs. They should include the isolation of rate changes and full transparency regarding how a rate change applies to the program. 

Finally, it is essential to look for a vendor that will work with the employer’s stop-loss carrier, providing proactive information to the carrier to ensure accurate stop-loss payments. The overall goal of a stand-alone care management program is to lower costs and improve outcomes. The best partners will do whatever is necessary to ensure the employer’s success.

Looking to the future

Employer healthcare costs will likely continue rising as our workforce ages and a growing number of employees choose to work past retirement age. According to the U.S. Bureau of Labor Statistics, by 2030 nearly 10% of the civilian workforce will be over 65 and the number of workers age 75 or over will increase by 96.5%. The challenge for employers is that older individuals typically have more—and more complex—chronic conditions that are more expensive to treat and require more care. 

The bottom line is that employers cannot afford to settle for underperforming care management programs. Stand-alone programs provide the transparency and analytics necessary to hold program vendors accountable and drive genuine results.

About Mary Bacaj, Ph.D.

As President of Value-Based Care (VBC) for Conifer Health Solutions, Mary Bacaj is responsible for leading the company’s business unit that delivers population health management and financial risk management services to more than 250 organizations. Conifer VBC is uniquely positioned as a partner to employers and unions, risk-bearing healthcare providers and health plans.

Mary joined Conifer Health in 2014 as Vice President of Strategy to help the company identify and implement solutions that ensure individuals receive the right care at the right time, while healthcare providers are aligned to improve the health of the population. She is a recognized subject matter expert in pay-for-performance programs, hospital and physician alliances, and healthcare reform.

Prior to joining Conifer Health, she was an Engagement Manager at McKinsey & Company, where she worked with senior executives at health systems and health technology companies on strategic challenges, such as population health management, hospital and physician mergers and acquisitions, and risk-based contracting.

What You Should Know: 

– Headspace, a comprehensive digital mental healthcare provider, and Castell, Intermountain’s value-based care subsidiary, have signed a value-based care (VBC) mental health partnership designed to improve health outcomes through a personalized care experience for members.

– The VBC mental health partnership will provide members with access to Headspace’s clinical offerings including their self-guided content, behavioral health coaching, and therapy in an outcomes-based payment model. This is a notable expansion of VBC for Headspace and is Castell’s first and only digital mental health provider in their network.  

Addressing the Growing Mental Health Crisis

The collaboration between Castell and Headspace aims to address the growing mental health crisis by engaging patients – wherever they may be on their mental health care journey – with robust behavioral health care offerings. The partnership will integrate Headspace’s offerings into Castell’s value-based model of care, which aims to improve clinical outcomes at a population level while reducing costs across the healthcare continuum.

Refer Eligible Members to Behavioral Health Coaching & Therapy

The partnership will allow Castell to refer eligible members directly to Headspace for behavioral health coaching and therapy. Those members will then have access to a team of behavioral health coaches, who respond to outreach in two minutes or less and provide care in the moment of need. Headspace’s coaches help to build coping skills and manage day-to-day stressors, and its licensed therapists are trained in a variety of clinical specialties and treatment modalities for more acute clinical care. Headspace’s care model is built to meet people where they are in the care spectrum and allows members to step up to higher levels of care or adjust over time, as their needs and preferences evolve.

“Our goal with patients is to help them have the most holistic view of their health. Being able to better address and integrate a patient’s mental health status is critical to treating the whole person and elevating the quality of care they receive,” said Jay Zerwekh, CEO of Castell. “We are thrilled to partner with Headspace to give patients access to behavioral health coaching and tools that can be tailored to meet their individual needs.”

What You Should Know:

• Today, CareFirst BlueCross BlueShield (CareFirst), the largest not- for-profit health plan in the mid-Atlantic region, and Ryse Health (Ryse), an operator of specialized cardiometabolic health clinics, announced a first of its kind quality improvement partnership serving individuals with uncontrolled type 2 diabetes in CareFirst’s commercial networks.
• The program will pair Ryse providers with CareFirst members in Washington, D.C., Maryland, and Northern Virginia with uncontrolled Type 2 Diabetes.

CareFirst BlueCross BlueShield, Ryse Health Partner to Accelerate VBC for Diabetes Patients

Ryse will combine a mix of in-person and virtual care interactions to help patients control their HbA1c and blood pressure and conduct timely diabetes-related health screenings so early detection and interventions are available. This patient-centered focus can help improve health outcomes, patient experience, and the affordability of care.

“Considered one of America’s top public health burdens, diabetes is a huge challenge for many of our members,” said Brian Wheeler, senior vice president of health services at CareFirst. “We’re excited for this partnership with Ryse, and to be implementing a hybrid management approach to diabetes care that improves access, strengthens the provider-patient relationship and supports members in a way that gives them the confidence to take control of their daily routines.”

CareFirst and Ryse began conversations in 2021, and in 2022 Ryse joined the second cohort class of 1501 Health, a national healthcare incubator program run by LifeBridge Health and Healthworx, CareFirst’s innovation and investment arm.

Both Ryse and CareFirst are driven by a value-based care system that focuses on care quality and patient health outcomes rather than the quantity of services. Ryse’s approach emphasizes frequent engagement with patients to help them improve their health. Ryse co-founder and CEO Richard Gurley said the company has observed that, on average, patients in the National Capital Area wait four months to see an endocrinologist and then often see their provider only every three to six months. Ryse strives to maintain new patient slots within two weeks, and the average Ryse patient has over 20 touchpoints with the Ryse team in their first three months. On average, Ryse patients see a 2-point decrease in hemoglobin A1c levels within 90 days and beyond, which outpaces traditional or virtual-only solutions by 50 percent or more.

The last few years have emphasized the need for high-quality healthcare for patients that is accessible and affordable for all. There is tension between stakeholders in the healthcare industry surrounding efforts to keep costs low and increase revenue, while not sacrificing patient experience. Years before the pandemic, the Affordable Care Act (ACA) revolutionized the healthcare industry and encouraged a new approach to balancing all the variables: value-based care (VBC). Whereas providers were previously incentivized to focus on volume and offer a wide range of services, VBC changed the focus to reimburse providers based on improved patient health, decreased risk for chronic disease, and an increased likelihood of living a normal, healthy life. Over the years, providers have embraced VBC, and most states have adopted the VBC model. 

In recent years, healthcare has undergone the same digital transformation as every other industry. As of 2021, nine in ten (88%) of US physicians had adopted electronic health records (EHRs), up from only 57% a decade prior. Another study found that providers spend an average of 16 minutes using an EHR per patient, meaning they spend hours daily using digital tools to manage health outcomes. At the same time, the global telehealth market, valued at $18 billion in 2020, nearly quintupled to $84 billion in 2022 and is expected to grow at 24% annually until 2030. 

Between the mass adoption of VBC and a massive digital transformation, the healthcare industry looks radically different from just a decade ago. Still, work is left to improve support connections between payers and providers to continue advancing patient outcomes. Below, I’ll discuss the importance of VBC in this relationship and the downstream impact on patients when there is a digital bridge between payers and providers. 

Value-Based Care Benefits All

VBC has proven to be a catalyst for change in the healthcare industry and has forced the entire system to reconsider its structure in several ways:

• Healthcare systems must segment patients into groups according to their specific health needs.
• Caretakers must split into interdisciplinary teams based on matching skillsets to patient needs.
• Teams must consider patient outcomes and cost to improve both quality and efficiency.
• Health systems must invest in technology that enables data collection and analysis and seamless communication between provider teams.
• Both providers and payers must redesign their patient billing practices.

Making these changes is not an easy fix that will happen overnight, but it’s necessary for long-term success for providers, payers, and other industry stakeholders.

Providers

VBC significantly impacts providers, particularly concerning burnout, which has skyrocketed in recent years. A 2022 American Medical Association study found that 63% of physicians had at least one instance of burnout in 2021, up from only 38% in 2020. Burnout has been linked to decreased quality of care and increased safety incidents, and it can adversely impact the bottom line if physicians leave their posts and providers have to foot the bill to fill the gaps in care.

With VBC, physicians can decrease their administrative paperwork burden because there is only one payment to cover the entire care process instead of billing after each procedure. Less time spent filling out charts and paperwork means more physician-patient interaction and more time spent focusing on their actual area of expertise: caregiving. 

Payers

Payers also benefit from a decreased administrative burden, which leads to cost savings. However, there are other financial ramifications. Payers have more control over costs because VBC leads to better health outcomes. With a decreased prevalence of chronic conditions, payers are spending less on the cost of patients’ long-term healthcare needs. 

VBC also focuses on preventative care, not just treatment after discovering an illness. Preventative care nips health issues in the bud before they become chronic conditions, leading to an overall healthier population that seeks less treatment in the long term.

Payers and providers can establish a mutually beneficial and supportive relationship under a VBC model. Providers are happier and at their best when performing their duties as healers. They focus on each patient’s specific needs, which benefits the population. It’s a “rising tide lifts all boats” scenario: a healthier populace spends less time seeking care, reducing the cost burden for payers and creating a more effective, efficient system.

The Importance of Digital Connection

More so than many other industries, healthcare has historically been a face-to-face industry. Patients go to a physical doctor’s office, the pharmacy for prescriptions, and so on. But, in recent years, the tide has shifted: according to a 2022 Department of Health and Human Services survey, one in four (23%) patients had used telehealth services in the previous four weeks. The relationship between biopharmaceutical representatives and providers has also become a virtual one, and a 2023 study from Boston Consulting Group found that 84% of physicians want it to stay that way. 

Technology also has a significant role to play in the payer-provider relationship. Payers need to meet providers where they are and develop a framework that allows providers to offer the highest quality care and improved health outcomes with an eye toward cost management. Technology can help implement value-based collaboration, including quality improvement and cost-containment initiatives that make the healthcare system more efficient. Platforms that implement automation for tasks like medical chart retrieval streamline the process and eliminate time-consuming administrative tasks.

Successful payer-provider collaboration also requires that all parties have data analytics tools; without data, value cannot be examined, and the value-based care system breaks down. For example, data can help identify an abnormally high 30-day readmission rate and implement changes to generate better initial outcomes. If SDoH are causing risk factors for a subsection of patients, data can identify how to implement more effective preventative care. 

Complementary, Not Adversarial

Better patient outcomes begin with a strong payer-provider relationship. The two sides can no longer stand on opposing corners and pursue disconnected agendas, where providers offer as many services as possible, and payers look for every opportunity to minimize their expenses. The focus must be patient-centric: if payers and providers work together with the patient always top of mind, higher-quality healthcare with better long-term outcomes at a lower cost will be the result, and everybody wins.

About Jonathan Malek

Jonathan Malek is the Senior Vice President and General Manager of the Provider Business at Veradigm, is responsible for provider-facing technologies and services, including EHRs, practice management and revenue cycle services. He has over 20 years of experience in healthcare IT, leading technologies and business activities which provide value across the spectrum of care, from individual patient visits to population health management.

What You Should Know: 

• Interwell Health, a value-based kidney care company, has recently expanded its network with more than 20 new physician practices–supporting the shift to more value-based kidney care. 
• The Interwell Health provider network now includes 1,700 nephrologists from across the country who are aligned with its mission to reimagine kidney care and help people with chronic kidney disease (CKD) live healthier lives. 
• These 135 practices range from large to small, rural to urban, and span 38 states nationwide. Interwell helps these practices succeed in value-based care agreements with regional and national payers, and the company is also the largest participant in the government’s innovative kidney care payment models. 

Value-Based Kidney Care Network Partners

Some of the 20+ new practices that have joined the Interwell Heath network include: 

• Caritas Medical Center (Georgia) 
• Columbus Nephrology (Ohio) 
• Commonwealth Nephrology Associates (Massachusetts) 
• Eastside Premier Nephrology & Hypertension PC (Georgia) 
• Fox Valley Nephrology (Wisconsin)  
• Hypertension, Nephrology, Dialysis, and Transplantation LLC (Alabama) 
• The Kidney Group (Ohio) 
• Metro Renal (Missouri) 
• Nephrology Associates of Central Maine (Maine) 
• Nephrology Associates of Tidewater LTD (Virginia) 
• Nephrology and Hypertension Associates LTD (Mississippi) 
• Portsmouth Nephrology (Virginia) 
• Queens Nephrology Associates (New York) 
  • aka New York Kidney Physicians PLCC 
• Randolph Medical & Renal Associates PA (New Jersey)       
• Salerno Medical Associates (New Jersey) 

Interwell Health supports physician practices by embedding care coordinators in the practice, providing personalized patient education, leveraging proprietary predictive models, and offering the leading nephrology-specific electronic health record technology. The company’s practice resources team helps streamline value-based workflows so nephrologists can focus on patient care. In addition, Interwell’s holistic care team of social workers, nurses, dietitians, and pharmacists support patients between doctor visits. 

What You Should Know: 

– Herself Health, a New York City-based healthcare company providing comprehensive primary care to women 65+raises $26M in Series A fuding led by Michael Cline of Accretive serving as the lead investor. The company has raised $33 million to date. Juxtapose also participated in the Series A.

– Founded in 2022, Herself Health provides value-based care to women 65+ with a focus on helping women feel seen and heard as they age in a way that the current healthcare system does not provide. 

Caring for women 65 and up, up, up

Women face unique social and medical challenges as they age, but most senior care is unfortunately one-size-fits-all. Herself Health was built to change that. Herself Health utilizes a holistic approach that goes beyond labs, medication, imaging, more doctors, and surgery and looks at the whole picture of a patient’s health and wellness, including mobility, mental health, social and behavioral health, the patient’s life journey, and quality of life.  Herself Health is working to ensure each one of its patients is properly cared for, listened to, and supported through this stage of their lives. 

“Women 65+ face unique health and social challenges as they age, and for far too long, their concerns, needs, and desires have been ignored,” said Kristen Helton, CEO of Herself Health. “That’s why we are designing Herself Health to be the value-based solution to improve outcomes and help women find joy, purpose, and better quality of life. Our fundamental goal is to elevate the patient experience and provide meaningful in-person and virtual support that provides women 65+ with a primary care experience designed specifically for them. In the few months since our launch, the incredible interest from patients clearly demonstrates that this model was desperately needed. This funding will allow us to expand our physical footprint, grow our digital, in-person, and community offerings and continue to build a world-class team of providers and experts to serve this community in the manner they deserve.” 

Expansion Plans

The latest round comes just six months after the company raised $7M in Seed funding. Herself Health currently operates one clinic in St. Paul, Minnesota with plans to expand its footprint substantially over the coming 18 months. 

What You Should Know: 

– Fold Health,a San Francisco, CA-based platform supporting value-based primary care raises $6M in funding from Iron Pillar and global angel investors. 

– Fold partners with leading value-based primary care groups, ACOs, health systems, health plans and digital health companies, to 10x the reach and effectiveness of collaborative care teams in their mission to radically improve outcomes.

Supercharge Primary Care

Despite the rapid shift to value-based care payment arrangements, existing solutions fail to support the needs required for success in outcome-based payment models: data-driven, consumer-centered, prevention-focused care. As a result, many primary care providers have resorted to investing in disjointed point solutions or building out their own tech suite, which takes valuable time away from treating patients. Fold Health’s platform integrates with electronic health records (EHRs) to enable customers to use modular tools to support their unique needs and optimize existing technology investments. Eliminating providers’ need to build software solutions from the ground up, Fold Health enables advanced primary care groups to achieve 3x tech-related cost savings.

Fold Health’s Capabilities

Fold Health’s Platform offers an integrated suite of capabilities including:

• ClinOps Efficiency Engine: A workflow engine that automates 60% of the work required to succeed in value-based care – including care gap closure, transitional care management, annual wellness visit completion, high-risk patient engagement, and attribution growth and protection.
• Care Team Enablement Suite: Unifies patient data, task management, omnichannel communications and scheduling to keep complex collaborative care teams in tight coordination.
• Patient Enablement Suite: A fully white-labeled patient web and app experience that allows patients to conveniently work with their care team, including self-scheduling, chart access, notifications management, and wearables/RPM data integration.

Expansion Plans

Fold Health continues to scale operations, most recently opening an R&D office in Pune, India in 2023. The company is also looking to rapidly expand it’s headcount across the US.

What You Should Know: 

• Aledade, a Bethesda, MD-based network of independent primary care practices raises $260M in a Series F funding round led by new investor Lightspeed Venture Partners, with participation from Venrock, Avidity Partners, OMERS Growth Equity, and Fidelity Management & Research Company.
• The new funding will be used to further accelerate the growth of Aledade’s primary care network and strategic alliances with national and regional health plans while continuing to enhance the technology and support the company provides to its partner practices and patients. Additionally, Aledade is continuing its momentum by welcoming two new members of its Board of Directors and a senior executive to lead its Medicare Advantage business. 

Market Expansion

By focusing on its mission and developing a model that succeeds only when practices succeed, Aledade has built the largest network of independent primary care practices in the U.S. with more than 1,500 independent primary care practices in 2023 spread across 45 states and the District of Columbia. Aledade’s more than 150 value-based care contracts collectively cover more than two million patients and more than $20B in total healthcare spending. Aledade now serves more than one million patients under the Medicare Shared Savings Program and nearly 250,000 patients under Medicare Advantage contracts with national and regional health plan partners.

Aledade generated revenue of more than $475M for 2022, representing more than 50 percent growth compared with revenue in 2021. This growth translates directly to increased payments to the practices that were part of the Aledade network in 2022. To date through 2022, Aledade and its primary care partners have saved the U.S. healthcare system more than $1.7B.

Executive & Board Appointments

Aledade has welcomed two new members of its Board of Directors and a leader of its team optimizing quality and shared savings performance under value-based contracts with Medicare Advantage plans. 

• Dr. David Blumenthal, M.D., M.P.P. was a practicing primary care physician for more than 30 years.  Most recently, he served as the president of the Commonwealth Fund, a national philanthropy engaged in independent research on health and social policy issues. Previously, he was the Samuel O. Thier Professor of Medicine at Harvard Medical School, and chief health information and innovation officer at Partners Healthcare System in Boston (now Mass General Brigham). He also served as the United States National Coordinator for Health Information Technology from 2009 to 2011.

• Paul Hennessy is the CEO of Shutterstock. Prior to that, Paul served 7 years on the Shutterstock board of directors. He previously served as CEO and a member of the board of directors of Vroom, Inc., and before that as CEO of priceline.com. From 2011 to 2015, Paul served as chief marketing officer of Booking.com.

Dr. Efrem Castillo joins Aledade as senior vice president for Medicare Advantage. Before joining Aledade, he was a senior vice president of clinical transformation at Optum. Prior to Optum, he was chief medical officer at United Healthcare Medicare Solutions. Earlier in his career, he was a physician-owner of Castillo Medical Group in San Antonio, Texas.

Value-based care and fee-for-service are two kinds of healthcare reimbursement models for pricing healthcare services. While the fee-for-service model is more traditional, the newer value-based care model has been gaining popularity in recent years.

Historically, value-based care has been harder to implement in behavioral healthcare due to difficulty measuring outcomes—it isn’t as simple as physical health. But, lately, this has been changing with the help of technology. This has had an impact on the behavioral health industry, as value-based care affords opportunities to providers to streamline their practices and to be rewarded for improving their quality of care, but also requires diligence and good recordkeeping.

Value-Based Care vs. Fee-for-Service: Understanding the Key Differences

Fee-for-service is based on services rendered and relies on the provider’s and patient’s judgment on when care is sufficient and has achieved results. In a fee-for-service model, each therapy session might be billed to the payor at a fixed rate. In contrast, value-based care models integrate outcome measurement directly into the contract between the provider and payor, with the provider being paid more money based on the effectiveness of treatment. This has been becoming a more popular mode of healthcare delivery, as it can reduce costs for insurance companies and other payors while rewarding excellent quality of care.

Some common outcome measurements in value-based care payment structures for behavioral health services include improvements in symptoms, quicker treatment success in fewer sessions, and fewer behavioral health hospitalizations. This has the advantage of aligning incentives for the provider with positive outcomes for the patient.

However, a disadvantage is that it requires more data collection and ongoing reporting to the payor, whereas fee-for-service is simpler. Neither model is perfect, but the value-based care model presents interesting opportunities for providers and payors when coupled with electronic health record (EHR) software that streamlines workflows for value-based care.

In this context, “fee-for-service” should not be confused with how behavioral health practitioners are paid. Some businesses choose to pay practitioners a salary (often, with minimum billable hours or a similar requirement), while others choose to pay them based on services rendered, sometimes as independent contractors rather than employees (if legally appropriate). 

Quality of Care: How Value-Based Care and Fee-for-Service Models Compare

Providers are ideally incentivized to provide better quality of care in value-based care models because it is tied to their pay. Some have described value-based care as “the future” of behavioral health. For instance, if a patient’s symptoms are equivalently improved in 10 therapy sessions instead of 20 sessions, under a value-based care model the provider might be paid based on that outcome (effectively, doubling their hourly rate). 

Fee-for-service models assume that quantity is quality, so if more medical treatments are performed, the provider is paid more. This conflict of interest can lead to treatment without improving the quality of care. At the same time, value-based care can provide incentives to rush treatment, although this is remedied with measurement-based care, depending on the objectivity of the measurements. For example, patient symptoms are often measured by patient self-report, which ideally is objective, but could be influenced if the patient misreports improvement (or, lack of improvement).

Out-of-Pocket Costs: How Value-Based Care and Fee-for-Service Models Affect Patients

Some providers find that they are underpaid in an insurance-based practice, as insurance reimbursement rates are often relatively low in the typical fee-for-service model. With support from an EHR that streamlines collecting and reporting on outcomes data, value-based care contracts are a great option to increase revenues while continuing to accept insurance. This also reduces patients’ out-of-pocket costs. Quality of care is measured with more sophistication when you transition to a value-based care model. This results in financial rewards for excelling as a provider, helps patients succeed and reduces attrition from lengthy treatment plans patients are less likely to complete.

On the other hand, some providers require patients self-pay in lieu of billing insurance. A fee-for-service model is common here and providers strive to convey that their behavioral health services are worth the out-of-pocket cost. Still, others, use a blended model including a mix of self-pay and insurance-paid clients. In either case, it is possible and sometimes easier for these providers to transition to a value-based care model, as self-pay clients are interested in paying more for superior quality of care, too. Of course, one must be wary of relying on self-report measures for treatment effectiveness in such cases.

Behavioral Health Services: Which Model is the Best Fit?

Although both models have their strengths and weaknesses, providers and payors are increasingly seeking out the value-based care model as a better fit in many instances. This follows trends in physical health practices where outcomes were historically easier to measure. With the help of technology, as well as research-supported measurement tools, it is now easier than ever to implement a value-based care model in behavioral health. Technology can help facilitate value-based care for providers, patients, and payors. This opens new opportunities for all parties involved.

Clinicians do not have to transition to a value-based care practice all at once. It can be done gradually, one payor at a time. 

Conclusion

The value-based care model contrasts with the fee-for-service model by financially rewarding providers for positive patient quality-of-care outcomes, whereas fee-for-service typically is paid based on the quantity of care delivered. In behavioral health, value-based care has historically presented problems pertaining to the ease and subjectivity of measurement; however, in recent years these problems have been alleviated through technological innovation and advancements in therapeutic and methodological research. This presents a golden opportunity for payors and providers to change their healthcare reimbursement models toward value-based care.

About Ram Krishnan

Ram joined Valant in 2020 as an experienced technology executive to lead the organization through its next stage of growth. His passion for listening to the customer and building strong teams, coupled with his demonstrated ability to drive scalability, provide a solid foundation for Valant to grow as it finds new ways to serve the behavioral healthcare market.

Ram’s robust experience began at GE where he graduated through the Informational Management Leadership Program and went on to lead the Global Radiology and Services business units. After nearly 15 years at GE, he went on to lead multiple SaaS businesses through critical phases of growth. Ram graduated from the University of Virginia with a BS in System Engineering and earned his MBA from The University of Chicago.