There is near-universal consensus that “value-based care” is a good and worthy objective.
Whenever unanimity embraces an idea, a thoughtful person may ask whether there’s true agreement. Or perhaps a cone of vagueness accommodates a variety of opinions and lets the eyes of the beholders see what they want to see. With value-based care, it may be the latter.
The Triple Aim identifies categories of objectives, with various worthy measures that can be useful. Value-based care is more strategic. Programs like pay-for-performance and bundled payments can help implement value-based care. But they are just tools in the kit.
When viewed as a strategy, value-based care has four foundational elements.
Provider-managed risk
In this context, “risk” refers to insurance risk. And it is the most significant difference in this era of provider-led, value-based care. Under value-based care, providers are seeking to move toward first-dollar premium risk.
In the most ambitious scenario, health systems are bringing new products to market. They either own the premium or are delegated full risk from a partner. But other arrangements also approach true value-based sense.
ACOs that include both significant upside and downside risk move participating health systems toward taking responsibility for the lives of individuals, rather than just their episodes. CMS is pushing its Medicare Shared Savings Program ACOs in that direction.
Population health programs
Health systems have deep experience in deploying patient-centered medical homes, care transition programs and disease management protocols. Value-based care places an even greater premium on targeting such programs at people with chronic diseases. It also targets these programs at those who are vulnerable to them because of socioeconomic reasons.
There is an increasing appreciation for, and sophistication in, treating social determinants of health (SDOH). This is slowly pushing health systems to engage even more assertively in the community to mitigate health risks.
Moreover, the increasing integration of SDOH in population-health approaches is creating the need for risk-bearing providers to rethink their networks. Networks of primary care physicians and specialists are necessary but no longer sufficient. Risk bearers now must integrate post-acute, social work, and community-based resources.
Data integration and stakeholder reporting
Health systems have significant investments in their own clinical and financial systems. They are continuing to integrate and add data sources to these systems in order to generate greater insight into their own performance and opportunities.
Payers also have made substantial investments in their ability to aggregate and report on patient and provider activities. Their common aim is to improve patient outreach and engagement.
Value-based care models have aligned these efforts. Now it is up to both payers and providers to follow through and truly collaborate on data reporting, sharing and aggregation.
Payer-provider collaboration
Past efforts at value-based models include the physician-hospital organization movement of the ’90s, closed-network managed care approaches. These have largely been efforts to “go it alone.” But they have rarely succeeded or been proven repeatable.
The cultural and business elements of the payerprovider relationship have long been contentious. Successful value-based care arrangements require both sides to leave the baggage behind and recognize that they need each other.
Resetting the payer-provider relationship takes time. It requires in-depth involvement from top-level managers in both provider and payer organizations.
Yet without it, providers won’t scale their population health efforts because they’ll avoid taking on risk. And payers will miss the opportunities to engage more fully with patients.
None of this is simple. None of it can be done quickly. But the demands of employers and patients for better, cheaper care — for care with value — leave the primary stakeholders little choice. They must engage with each other on a sustained, collaborative journey toward a shared vision.
This article first appeared in Managed Care as What We Talk About When We Talk About Value-Based Care.
