Promise
From Volume to Value
VBC has promised primary care physicians a shift from care being reimbursed based on volume to being paid upfront or prospectively based on population resource needs and incentivized retrospectively for improving cost and quality outcomes. Compared to the FFS model, which emphasizes face-to-face, encounter- based care with a physician, prospective payment ensures consistent revenue to cover the costs of caring for an attributed population regardless of whether that care is delivered face-to-face, via secure message or phone call, by a nurse, or even without directly interacting with the patient. This consistent revenue also relieves the pressure to generate an excessive volume of services.
Peril
A Foot in Two Canoes
The current transition to VBC can present perils in getting to the promise. Primary care practices do not have a path to transition 100% of revenue from FFS to VBC overnight. This means that VBP adoption is a process of migration, during which already fragile practices operating on a thin profit margin and overwhelmed by the consequences of FFS are at risk of collapse due to burden that is out of proportion to incentives offered.
Voices
We get a monthly amount amd some amount can be held out for risk. Or you can have an amount that can be withheld at the end. But, all of these (100% of our patients) we get a Per Member Per Month amount.
A very interesting thing - with COVID, a lot of practices that were on P4P in Hawaii, patient volume dropped down and everything went to home, but guess what? Our checks kept coming! That’s a pretty interesting dynamic!
We have a whole multiple-level pyramidal model evaluation. I just get reports handed to me. But having good staff that understands how to manage this is the real process.”
We are an entirely VBC model usually urban densities, so we can have the scale that is necessary for our care model.
We focus on multi-complex conditions, unengaged patients with the reset of the HC system, difficulty as far as social services and SDOH, and the subset that crosses all of that is serious mental illness and substance use disorder. We don’t shy away from that either.
We use an interdisciplinary team which includes significant use of CHP (community health partners). They are the main point of contact for the patients which relieves a lot of responsibilities on the physicians’ part, where using an interdisciplinary team. We relieve a lot of burden that way.
Success Factors
Infrastructure
A significant factor in burnout is the amount of work to be done divided by the resources
available to do the work. As such, there seems to be a threshold of financial investment needed
to support infrastructure that is sufficient to enable success in VBC and reduce the associated
risk of burnout. In practices with a team, whether integral to the practice or affiliated through a
network organization, the additional work of VBC was more manageable, and burnout was
lower. The adoption of specific technical solutions introduced additional efficiencies, which
helped contain operating expenses and enable both clinical and financial success.
Capitation Factors
It should also be noted that, in general, practices with capitated models experienced less
burnout than those with payment models designed around retrospective bonus payments.
However, even in capitated models, some specific factors key to success were identified, and
these factors support the findings of a 2017 research study published in Health Affairs, which
modeled (in simulation) the impact of both capitation rate and percentage of total revenue from
capitation on financial outcomes in a primary care practice. Our findings indicate that both the
capitation rate and the amount of total revenue from capitation are crucial factors in relieving
burden/burnout and achieving ongoing financial success in VBP models.
Quality Measures
The effort required to identify, deliver, report, and get paid for a set of payer-driven quality
measures is not insignificant. In our study, we noted that practices with fewer payer contracts
had less burnout, likely due to simpler workflows to achieve success. This confirms what is
already widely known: Lack of alignment across payer programs in specific quality metrics,
reporting mechanisms, and performance management platforms introduces additional burden
into primary care practices and contributes to burnout.
Contract Quality and Innovation
The most successful practices in our cohort benefited from innovative and savvy contract design
between the practice and the payer, sometimes involving partner health systems. Practice
leaders who worked closely with their payer organizations to design contracts that recognized
the power of primary care to influence downstream utilization patterns and costs of care of an
attributed population realized better financial outcomes for the practice, reported a better
experience of delivering care, and enjoyed the least amount of burnout.
Innovations Needed
Evaluations have identified innovations that appear essential for more effective and efficient
success in VBP. We asked participants for their wish list innovations, and their answers provide
insight into the categories of innovation needed, including:
Coding and Reimbursement
● Automated coding of gap-closure for Category II CPT Codes
● Higher capitation rates
● Better reimbursement for behavioral health care
Risk and Risk Adjustment
● Including social drivers of health in risk-adjustment scoring
● Risk-adjustment paneling and resource planning
● Risk prediction and intervention
Data and Transparency
● Honest, actionable data and transparency
● Standardizing all quality measures across all payers
● Making data about community and government-based services transparent
Practice Management
● Streamlined management of attribution
● Capturing external data into the EHR
● Direct connection to an assigned representative of each VBC arrangement
● Practice mentorship program that provides access to practices with experience in VBC
● Practice support services to make it easier for small practices to adopt VBC
VBC Innovations
To be successful in value-based care, practices must transform through a set of innovations
VBP Contracting
The know how to be successful in managong risk-based contracting
Team-based Care
Implementing pyramidal team based care to support value-based care