Contributed: Opportunities for innovators in the next wave of value-based care

Wider adoption of value-based care (VBC) would be a boon to our healthcare system by lowering costs and improving outcomes for all three P’s: patients, providers and payers.

The Centers for Medicare and Medicaid Services (CMS) has led the charge on driving VBC adoption with a series of specialty VBC programs, including July’s launch of the Guiding an Improved Dementia Experience (GUIDE) Model. GUIDE will build off the success of the ESRD Treatment Choices (ETC) and Enhancing Oncology models. 

Alongside CMS’ leadership, a wave of VBC companies has emerged in recent years, mostly focused on primary care providers (PCPs) serving the senior population. While they’ve found some success in helping stakeholders transition from fee-for-service to VBC models, several headwinds are hindering further adoption across the broader landscape of primary care and specialty care, as well as additional payer lines outside of Medicare Advantage, such as Medicaid and Commercial.

The COVID-19 pandemic led to once-in-a-lifetime patient behavior swings that harmed both value-based and fee-for-service providers. Utilization of elective procedures plummeted, resulting in a drop in the government estimate of how much money was required to care for each patient. Once the pandemic subsided, utilization jumped well above historical benchmarks. Now, many VBC companies spend more on care while facing more government reimbursement challenges.

VBC still has tremendous potential, but advancing it will require innovation that unlocks new stakeholder participation and drives collaboration across the care journey. There are three significant areas of opportunity to accelerate VBC adoption and manage costs downstream.

1. Enabling PCP-to-specialist workflows and collaboration

PCPs sit at the center of the VBC transition, since they are often the first point of contact dictating patient behavior and treatment pathways. However, many PCPs do not yet have the resources or visibility to influence the full patient journey and, therefore, do not feel confident taking on risk. Effective value-based care requires constant engagement between PCPs, specialists, patients and payers, but PCPs do not yet have the full tool kit or bandwidth to lead the charge.

Aligning primary and specialty care providers will be essential for the next wave of VBC. While PCPs have been on the vanguard of VBC adoption, the larger opportunities for improvement are with specialists, who have been slower to adopt VBC. Traditional VBC models require providers to manage a patient’s entire care journey, which is impossible with the limited scope that specialists typically have. Each specialty has unique characteristics, workflows and economic drivers that must be considered to build an effective VBC model.

For specialists to embrace VBC, there needs to be significant improvement across three key areas: referral management, analytics and effective incentive models.

AristaMD, for example, is working to improve the referral process between PCPs and specialists to make the process of navigating specialty care more efficient. Other companies, such as Care Journey (acquired by Arcadia), Clarify Health and Embold Health, are aiming to improve analytics and transparency to measure outcomes and drive performance in specialty care. To help specialists capture the economic upside of value-based care, companies like HOPCo, Vori Health and Commons Clinic are developing programs aimed at effective incentive models around musculoskeletal care.

2. Engagement-as-a-service: The last mile of care delivery

VBC is ultimately about improving long-term health outcomes for patients. For it to be effective, patients must be engaged and invested in their care at all stages of the journey. 

In the current healthcare system, patients can often fly under the radar, resulting in delayed diagnosis and missed handoffs in the care journey. With the right mechanisms, a VBC program identifies at-risk patients and connects episodic health data over a longer period to get a comprehensive picture of the patient’s health – and enable the last mile of care. 

The key is engaging patients early and often. Companies like Radiant Graph, Pyx Health and GroundGame Health are working to improve initial patient identification and outreach. Others, like Wider Circle, create on-the-ground services like peer support groups that help patients navigate care and access key resources.

Lastly, there are solutions for specific treatment pathways that are built to enable last-mile engagement. Monogram Health uses a comprehensive, evidence-based care model for chronic kidney disease with personalized care plans to improve engagement.

3. Facilitating new arrangements with payers

Unlike fee-for-service models, VBC arrangements are not one-size-fits-all. Providers may start with upside-only arrangements, then move into bundled payments or shared savings, before eventually taking on full risk.

Unfortunately, most providers don’t have experience underwriting risk or negotiating these types of contracts. Many providers observe that negotiating with payers puts them at a great disadvantage, since insurance companies’ core competency is built around actuarial modeling and aggregating comprehensive longitudinal data. Adding to the strain, reimbursement and data feeds from payers to providers are often significantly delayed, which can create further distrust and a lack of transparency.

Several companies are working to facilitate payer-provider interactions by supplementing key VBC operational capabilities. Players like Accorded and Arbital are building scalable actuarial analytics to aid providers in contracting and reimbursement. There is also still a need for innovative companies that accelerate claims reviews to expedite payments and reduce payer and provider administrative burden.

The next generation of VBC

Just as there’s no one type of specialty provider, there’s not one approach that will work for all specialties. It’s critical for providers to look at different ways of delivering VBC based on the specialty and the way care is delivered within that specialty. Multispecialty models and companies that enable close collaboration between PCPs and different specialty areas, patient populations and settings of care are much needed.

Value-based care can help lower costs and improve outcomes for patients, providers and payers alike. This is a unique moment to innovate a better healthcare system for all stakeholders and explore new approaches to take on risk outside of just the Medicare primary care population.