One of the first and most important challenges an organization faces when moving from strictly fee-for-service (FFS) healthcare delivery to value-based care (VBC) is aligning physician and provider compensation to the new priorities of VBC. If this gets left to be done “later” or not at all, the disconnect between incentives will make VBC success very difficult. 

As a follow-up to the VBC Drivers article on Preferred Provider Networks, this article will focus on the importance of at-risk Primary Care Physicians engaging Specialty Physicians in driving Value-Based Care (VBC) outcomes through the development of High Value Networks (HVN) for continued performance improvement in VBC models.

Throughout this series of articles, we’ve discussed value-based care (VBC) drivers of gross income – attribution, risk coding and activities-based bonuses – and spent a good amount of time on drivers of net income, those that lower medical expense. Of these, we have looked at access, Annual Wellness Visits, and managing patient care. These six levers get pulled by most all organizations and practices to some degree regardless of their position on the VBC spectrum.

In this series on the drivers of success in value-based care (VBC), we’ve looked at elements that improve gross revenue and are halfway through the discussion of VBC components that help decrease medical expenses. This installment will tackle the complex topic of “Care Management,” so buckle up and hang on!

The Health Care Payment Learning and Action Network released a measurement of Alternative/Advanced Payment Models (APM) for 2023, showing the types of payments physicians and providers received overall and based on payer type. The measurements show a positive trend toward value-based care (VBC) payments, and the breakdown by payer was even more telling.

If you’re new to Value-based Healthcare, first of all, Wake Up! Where have you been? Just kidding. Even though I’d like to think that the concepts and practice of value-based care (VBC) are well-known to all and practiced diligently by most – VBC as a mode of operation in healthcare delivery that improves outcomes, improves patient and physician experience, improves revenue for physicians, and decreases overall cost of medical care – the realist in me recognizes that’s definitely not the case.

Earlier this month, the Centers for Medicare & Medicaid Services (CMS) announced a new primary care model aimed to improve health outcomes and better enable coordinated care with specialists to ultimately provide more seamless, high-quality, whole-person care. 

The U.S. healthcare market continues its trend toward vertical integration with the launch of Risant Health, a new value-based care, integrated health organization recently announced by Kaiser Permanente and Geisinger Health. Geisinger, a Pennsylvania-based, ten-hospital system, will be the first to join the organization via acquisition (pending regulatory approval).

The Centers for Medicare & Medicaid Services have advanced value based care significantly in the last several years, and in a somewhat expected, yet bold move in October 2021, specifically said that they expect all traditional Medicare beneficiaries to be treated by a provider in a value-based care model by 2030. CMS rarely uses such superlative terms (all traditional Medicare beneficiaries), and the Centers for Medicare & Medicaid Services Innovation Center (CMMI) has five stated strategic objectives to achieve this massive undertaking.

Quality measures are a key aspect of primary care, not just because value-based care requires satisfaction to receive incentive payments, but because they can impact patient wellness. At a base level, it is common sense to evaluate an individual for early signs of diseases that could evolve into a more serious issue such as cancer or heart disease. Unfortunately, not all insurance payors have the same idea of what quality measures should be tracked or even what the target values should be. For example, one payor may say hypertension is defined as having a blood pressure of greater than 130/80 while another may say 140/90. Uncontrolled diabetes may be defined as an A1C greater than 8 for one payor and greater than 9 for another. A lack of consistency in these expectations causes confusion for primary care practices and can result in unmet quality measures.

Primary Care Providers (PCP) are problem solvers trained to learn as much as they can about the entire human body. As soon as the patient begins to describe their concern, the PCP is processing the information and evaluating possible solutions or treatments. It is often difficult to determine how much time is needed for a visit because they are trained to not just look at a single problem, but the whole person. Value-based care and mandatory quality measures (or risk losing money) have made the primary care visit even more complex. If a provider runs late, patients become irritated and upset but expect the provider to give them the amount of time needed for whatever “oh by the ways” they mention even if it wasn’t included in the reason for visit.

It’s the beginning of a new year, so you’ll be hearing a lot about Medicare risk coding and the importance of risk coding. You’ll most likely hear the same story from many different sources - beginning January 1, those patients with amputations suddenly have limbs grow back and patients with certain conditions no longer have those conditions. You as practice leaders and physicians are told by multiple sources about how important capturing appropriate condition coding for your patients is.

Primary care, and the leaders, physicians, clinicians, and support team within those primary care offices, are truly at the heart of making healthcare better. As we close out 2022 and enter 2023, there is no better time to focus on something that’s often overlooked in the business of primary care - you and your intentions.

As a company working towards a value-based care program, the number one thing needed for success is the alignment of your incentives with each of your team members. 

A misconception exists that physicians must choose between practicing fee-for-service (FFS) medicine and Value-based Care (VBC). We often hear the phrase "a foot in two canoes" to represent the perceived need to abandon one watercraft for another identical one in their move to VBC, the notion being you can't simultaneously be in both payment models, and you need to choose. This perception can be paralyzing when considering making a business move within one of these practice / delivery models.

While it’s nearly impossible to attribute just one, or even a handful of causes to the lack of traction or success for value-based care, it is possible to assess influence and recommend focused avenues for positive change.