Despite these experiences, it is still unclear whether value-based payment really moves the needle on the quality of all healthcare systems. A systematic review of 59 studies published in April 2020 showed overall that taking risks reduces costs due to things like reducing low-value services and moving complex patient care to an outpatient setting.
Overall, however, the quality changes were small, but better than their fee-for-service counterparts, according to researchers at McMaster University in Canada.
“We are in a stage where there has been a lot of learning, but there is not enough consistency in how the models look, or how the results have been evaluated or, frankly, significant enough changes in patient outcomes, that we can still draw conclusions, ”said Suzanne Delbanco, CEO of the nonprofit Catalyst for Payment Reform.
Overall quality is not guaranteed to improve within the models themselves, and individual vendor performance can also vary widely between paid programs. To go beyond merely obtaining financial incentives for meeting quality benchmarks to a point where vendors are truly ready to take more risks, a serious investment should go into infrastructure such as data analytics capabilities, predictive modeling and care management, according to the Integrated Healthcare Association. in California.
IHA has helped synchronize quality metrics and collect data on value-based agreements, primarily in outpatient settings, and is currently studying what specifically helps a healthcare system achieve greater cost savings and better quality outcomes.
“There’s so much difference in what (payers) define as ACOs, you really don’t know what they’re offering you, unless you have some way of looking at performance,” said Jeffrey Rideout, IHA CEO.
But in general, at least in California, integrated groups that accept any level of risk through capitation have quality scores nearly 10% higher than those that do not, and those that accept full risk have scores of quality 13% higher than your fees. counterparts for services. The IHA data is based on a composite score on 12 chronic clinical quality and prevention measures for approximately 7.5 million of the state’s commercial HMO and PPO population, excluding Kaiser.
Catalyst for Payment Reform also collects quality data from payers offering commercial-based value contracts. Delbanco echoed Rideout’s sentiments: payers typically determine performance improvements based on a few selected measures.
“So we created what we call a kind of nutrition label for ACOs, a set of metrics that we wanted complete and complete reports on, and for the last three or four years we have asked health plans to report on them.” Delbanco said. saying.
Those metrics include things like potentially avoidable ER visits, high blood pressure control, and remission of depression at six months. Employers can access the organization’s database to see where these agreements to reduce costs and improve quality actually work, and where they don’t. Performance improvement can vary widely from vendor to vendor, even within the same ACO.
Esser at SG2 estimated that 20% of healthcare providers are in some level of risk-based contracts and will move towards higher capitation because the pandemic focused more on the problem of fee-for-service payment.
And then there are the providers who still have feet in every payment model, but haven’t invested much in creating more comprehensive services so patients have a better chance of getting better-quality outcomes, such as shorter hospital stays or fewer readmissions.
And the remaining majority have yet to commit. Perhaps they experimented with an ACO in the early years and the potential return was not worth the investment and work involved. Esser estimated that about a third of providers have tried and stopped participating in an alternative model or have not yet reached those agreements.
Fields at Mount Sinai said the vendor experience may still be more about ticking boxes for value-based tasks, and not really being innovative.
Many of the providers that have not yet entered value-based contracts include independent physicians, which is one of the main reasons Blue Cross Blue Shield of Minnesota recently launched a program to provide care physicians Primary part of the necessary infrastructure: a Stellar Health technology platform that offers information about the data. The program offers incentives to physicians and staff for having a conversation about the need for a breast cancer screening test and then scheduling the patient appointment.
“What we’re working on right now through these value models is trying to unleash some of the revenue that they have historically earned through fee-for-service and deliver it to them in a different way,” said Karen Amezcua, senior director of providers. associations in the Minnesota Blues.
Outside of the primary care program, most of the insurer’s value-based contracts are with health systems. Approximately 60% of the members of all lines of business participate in some type of value-based arrangement.
An added benefit of being part of a value contract, Amezcua said, is that the insurer reduces the use of utilization management techniques like prior authorization. “Because we know they are at risk of acting, we don’t need to do that for them,” Amezcua said. “That’s one of the benefits that I think providers see from moving toward value.”
CMMI is expected to reduce the amount of Medicare fee-for-service ACOs in the coming years. There has been criticism that there are too many programs to keep incentives aligned, adding to the administrative chaos of managing various patient populations.
Medicare Advantage itself is an alternative payment model. Plans that earn a CMS four-star or higher rating receive a 5% pay bonus, and another 5% of revenue is passed on to at-risk medical groups. And the population that chooses these private plans is growing.
“If our star rating is a little higher, because we’re hitting the milestones for blood pressure (drug) refills and colonoscopies, then we get a bigger piece of the pie,” said Dr. Matt Lambert, chief medical officer for Curation Health, a clinical support platform aimed at helping providers move from fee-for-service to value.
Lambert said he expects to see a lot of movement within CMMI under Biden to develop more models and focus on what has and hasn’t worked so far in an effort to get suppliers to take more risk.
And whatever the impact on quality, legacy healthcare systems will come under increasing pressure in the coming years to switch to value-based models of care and remain competitive with the increasing prevalence of providers. external such as Oak Street Health or ChenMed. These disruptors take full risk to their Medicare patient population, allowing them to take a population health approach to individual care.
“It could be argued that it is better to start eroding your business model in a planned way over time, rather than having a third party enter the market that is anxious and has no hospital balance sheets to worry about and will reduce the utilization of aggressively targeting the cost of legacy providers, ”Esser said. “That is even more risky.”
VillageMD’s Martino said they are in talks with various health systems to manage their participation in value-based contracts.
“They said, ‘We are very good hospital operators, but we are not that good medical administrators.’ Maybe there is a way to structure partnerships to help them navigate the curves of change of value-based care, ”said Martino. “And we will continue to be a really good specialty, institutional and outpatient provider.”