Payers and Practices Partnering on Value-based Initiatives

About 35 percent of family physician Michael Munger's contracts with commercial insurers are in value-based care. The Overland Park, Kansas-based family physician plots a marked increase in such contracts to about two years ago.

One of the hardest parts of being successful with value-based care with commercial insurers - as is the case with CMS - is making sure that physicians and the entire care team are all aligned with the outcomes that illustrate success. What that requires, Munger says, is transforming the thought that a practice is providing point-of-care services. Instead, practices need to embrace the opportunity to manage the health of the patient population they're serving. For example, practices need to make sure they're monitoring the health of their diabetic patients and those living with chronic obstructive pulmonary disease and other chronic conditions.

In order to achieve that level of success, every single member of the clinical team needs to be "rising to the top of their expertise and licensure," says Munger, who's also president-elect of the American Academy of Family Physicians (AAFP). At his practice, that means that a care coordinator - a nurse who is working as part of the overall team - reaches out to the patient in a proactive way shortly after their visit to an emergency room, for example. Nurses are also triaging patients' questions, discussing changes to their medical therapies, and scheduling necessary tests, instead of having patients wait to hear back from Munger or one of the other nine doctors at the practice.

This change didn't happen overnight, however. What the practice found beneficial was building trust across the entire team. Case in point: Everyone on the team needs to trust that one of the nurses will take ownership of following up to make sure patients are up-to-date on their flu shots and immunizations. And, on a practical level, this teamwork also requires Munger and the other physicians on his team to take time to introduce patients to other members of the care team. To achieve this, Munger takes a couple of minutes to introduce his patients to the care coordinator on his team - and he'll mention that patients should expect to hear from her within six months about their flu shots and immunizations; he and the other physicians at his practice provide these introductions anytime there's a need for care that's facilitated by one of the practice's two care coordinators.

Because various members of the team take ownership for different aspects of patients' care, each team member is empowered, says Munger. That's a transformation, compared to the situation a few years ago, when patients looked to their doctor alone as being responsible for their healthcare, he adds.

How do you get there?

Munger's practice has been certified by the National Committee for Quality Assurance (NCQA) as a Patient-Centered Medical Home since late 2013, so his team has had time to figure out what works best for them. But these lessons are being learned the hard way at small- and medium-sized physician practices around the country.

According to Veeneta Lakhani, vice president of provider enablement at health insurer Anthem, her organization has made a commitment to small- to medium-sized physician practices for the last four years. The path to success for practices of this size is for commercial payers to assess providers' readiness to take on risk and the proactive management of the patients in their care, she says. (Forty-six percent of Anthem's medical spend was in value-based care in 2016, which includes physician groups of all sizes, says Lakhani.)

For example, some of the larger practices Anthem works with have more experience managing large patient panels, whereas some of the smaller practices need "quite a bit of investment" by Anthem to enable them to be successful with value-based care. From a practical perspective, that means that payers have to help practices build the right kind of structure, access to data, and insight into appropriate staffing to achieve success in value-based care, she says.

The payer's investments include a provider-facing portal with reports and data for providers. The portal also highlights high-risk patients, ER "frequent fliers," open care gaps, generic drug opportunities, and other actionable information. Anthem's staff maintain active relationships with their counterparts at physician practices, especially those with high concentrations of Anthem members. Collaborative learning opportunities - such as a recent webinar on getting adolescent patients to come to the practice for well visits and immunizations - are also made available to providers.

Anthem hears a lot of feedback from practices that they're looking for "payer-agnostic solutions," says Lakhani. For example, practices are asking for standardized score cards to use for reporting data to different payers. It's challenging for practices to have to report information in different ways to commercial payers and CMS. That's where we need "industry alignment," she adds. Software solutions from vendors can also be helpful in this regard.

Population health management vendors are starting to standardize around measures that are commonly being used in value-based programs, particularly the Healthcare Effectiveness Data and Information Set measures, says Lakhani. "As population health tools continue to mature, they're finding the commonality across payer programs and streamlining the amount of effort required to participate in multiple programs with multiple measures."

Also on the topic of data, physician practices need to know the care paths their patients are on. With that information in hand, practices can reach out to patients in a proactive way, she says.

At Munger's practice, the patient experience today is very different than it was a few years ago. Today, a team member at the practice is calling diabetic patients to remind them to schedule appointments and to have their blood work done, he says.

Meeting practices where they are

Most of the small- to medium-sized practices UnitedHealthcare engages with in value-based care contracts are in what Scott Hewitt, vice president of value-based care contracting, calls its "metric-specific programs." These programs reward practices when they can demonstrate that they're proactively managing the health of their patients.

In practical terms, this means if the practice gets all of its relevant patients screened for colorectal cancer, for example, the practice receives a bonus check. Hewitt says approximately 40 percent of the payer's $53 billion in value-based care contracts in 2016 was in metrics-based programs with physician practices of all sizes. The payer expects to have more than $65 billion in value-based contracts in 2018.

As practices gain more experience in value-based care, they're more equipped to take on arrangements where they're paid for bundled or episodic payments, he says. For example, that could include accepting a lump sum for a knee or hip surgery. Hewitt says that, while success in the metric-specific programs doesn't automatically mean that a practice will be able to move to a bundled payment program, experience in the metric-specific programs gives practices a better understanding for ways to ensure that their patients are receiving optimal care in the right place, at the right time, and at the right price.

Approximately 20 percent of UnitedHealthcare's contracts are in this second type of value-based contracts. The remaining 40 percent of the payer's value-based contracts are with large hospitals and integrated delivery networks.

Practices look to UnitedHealthcare to help determine members' gaps in care and best practices in providing that care to patients, says Hewitt. For smaller groups, in particular, figuring this out on their own would be too challenging, as they don't have the infrastructure to get at this data alone. Still, Hewitt says practices have shown they're willing to make these changes once they have the data and the tools they need.

UnitedHealthcare sends providers information on areas such as patient gaps in care, financial data, referral patterns, lab usage, and pharmacy prescription patterns. This information is sent to providers electronically or by mail, since there are still many providers that don't have access to the Internet, says Hewitt.

His advice for practices that want to increase their success rate in value-based care includes:

• Engage with payers to ensure that you have mutually aligned goals. "You can better care for members when you know how [you] can work together to achieve that," Hewitt says.

• Get as much patient data as possible from payers.

• Implement processes within the practice to provide the highest level of care.

• Determine with payers where there may be inefficiencies in the delivery of care. "Everyone thinks they're providing the most efficient care," he says. "Unfortunately, that's not always the case."

The big picture

While Donald Crane, president and CEO of CAPG, a leading U.S. trade association for physician organizations practicing capitated, coordinated care, says that commercial payers are largely following the direction set by former-Secretary of Health and Human Services Sylvia Mathews Burwell in March 2016 – namely, that 50 percent of Medicare payments would be tied to quality by 2018 – some of the organization's members tell Crane that not all payers are embracing this level of value-base care. There's been "a little bit of tug of war" between payers and providers in terms of who should hold risk. In fact, some plans prefer fee-for-service arrangements, according to CAPG members, he says.

"Where there are risks, there are rewards," says Crane, adding this is the reason some payers are resistant to embrace value-based care in their contracts. Payers' embrace of value-based care largely depends on the payer's strategic focus. If a payer wants to have more control over the delivery of care, fee-for-service is probably a better fit. However, if the payer's focus is on eliminating waste, coordinating care across the continuum, and achieving higher quality scores and better patient care, they're moving toward value-based care, he says.

Value-based care is "here to stay," says Lakhani, in spite of uncertainty about the future of healthcare reform.

While no value-based care program is "designed in perfection," she sees a shift toward moving risk from payers to providers, including awareness by payers that many decisions about patient care are "better handled with much better results in physicians' hands. That's a shift that's positive and [it's] here to stay."