Helping make value-based care work for primary care

© magele-picture - stock.adobe.com

Value-based care has been heralded as the future of healthcare for more than a decade, but it has yet to fully arrive.

This gap is particularly evident in primary care, which must be on board if the promise of value-based care (VBC) is to be achieved. The Commonwealth Fund, a private U.S. foundation dedicated to improving healthcare, recently issued a report exploring why primary care has been so slow to adopt VBC.

According to a 2022 Commonwealth Fund survey, just 46% of primary care physicians (PCPs) reported receiving any value-based payments. Commonwealth Fund researchers found that PCPs weren’t opposed to VBC in principle. In fact, they long to get off the fee-for-service (FFS) treadmill, enabling them to spend more time with patients while providing comprehensive, proactive care. The problem, they say, is that VBC and its payment models are not designed or implemented in such a way that makes it possible for them to participate.

The solution is not to abandon VBC, but to make it work for primary care. Until the model is refined and provider concerns are addressed, independent PCPs are stuck between staying with FFS and its inadequacies or running the risk of failing under a VBC model that doesn’t work for them.

One immediate solution for primary care practices is to collaborate with an organization known as a Value-Based Care (VBC) “enabler.” These enablers help to mitigate the ongoing challenges within VBC, offering a smoother transition for PCPs to adopt this alternative payment model.

Let’s delve deeper into the major barriers and explore potential solutions.

Administration – The average PCP who provides services to patients covered by Medicaid needs to see on average 25 patients just to break even. This financial strain is compounded by the varying quality metrics imposed by managed care organizations that oversee VBC contracts. Consequently, many PCPs find themselves overwhelmed by the additional paperwork and tasks required. Smaller, independent primary care practices, in particular, lack the necessary resources, such as staff and technology, to manage these demands. As a result, these practices often struggle to earn VBC payments or opt out of VBC arrangements altogether.

These practices require technology that can seamlessly integrate patient data from various sources, including their own electronic health record system. This technology should enable them to analyze and manage the data necessary to deliver high quality, evidence-based care including identifying patients who need to be prioritized for wellness visits, chronic care visits, or transitions of care, regardless of their payer. Fortunately, such technology is available through VBC enabler organizations, eliminating the need for practices to invest in new technology infrastructure, which many cannot afford.

Finances – PCPs may be wary of payer contracts that put them at financial risk, particularly if their panel consists of higher acuity patients. Outcomes-based reimbursement can be unpredictable, akin to a black box that is unknowable until year-end (or even later due to dependencies on claims processing).

Because VBC enablers often concentrate on specific patient populations – such as those covered by Medicaid – these organizations may be particularly suited to helping PCPs navigate financial structures that are less familiar. As well, in some cases, enablers may be willing to take on downside financial risk or provide upfront payments based on addressing various gaps in care, providing further financial stability to PCPs.

Patient engagement – PCPs often experience frustration when trying to improve their patients’ treatment adherence amid challenges related to social determinants of health (SDOH). For instance, a patient may need help managing multiple chronic conditions while also facing unmet social needs, such as food instability, which further complicates their care. A VBC enabler, particularly those focused on Medicaid populations, can help address SDoH, which heavily impacts a patient’s overall health and their ability to access care. A VBC enablement partner may also complement care provided by PCPs with multi-disciplinary field teams that include nurse practitioners, care coordinators and even chaplains, to address SDoH and help patients re-engage with providers and receive personalized care.

The VBC enabler helps payers, as well. Here’s how:

Network optimization – Payers need to align more of their network providers into VBC agreements at a scale that allows them to share risk and reward. They also must optimize network performance, particularly with outlier practices. This can be accomplished as the VBC enablement partner brings more PCPs into the network through a proven clinical model, proprietary technology and an activity-based payment structure that corresponds with overall goals. Payers benefit as it becomes easier for providers to meet VBC goals and transform their care models to promote health and well-being.

Health plan dynamics – Payers need more effective strategies to improve quality and cost outcomes for members with complex needs and those who have been historically marginalized in terms of healthcare access. Additionally, payers must find ways to differentiate themselves within their respective markets.

An enabling partner provides PCPs with the technology, analysis, financial support and SDoH initiatives to allow them to deliver high-quality care, with a particular focus on marginalized and underserved communities. This helps payers meet their goals. Additionally, the partner’s deep connection and support in communities helps payers develop a strong presence.

Proven results in Medicaid

VBC models augmented by an enabling partner have been proven across thousands of PCPs and multiple states. PCPs, particularly those in disinvested communities, should find an enablement partner that can remove administrative and operational challenges to support them and health plans in achieving VBC success. These supportive partners align, engage, and assist providers and payers, allowing them to focus on the patients and communities that need it most. Ultimately, all parties, especially patients, benefit and thrive.

Michael Poku, MD, is Chief Clinical Officer for Equality Health, a value-based care enabler with a Medicaid-first model uniquely equipped to address the needs of diverse and historically underserved populations.