Expert Forum: COVID-19 puts new spotlight on value-based care transition from fee-for-service
By Carley Thornell | December 1, 2020
COVID-19 has thrust a spotlight on a significant number of issues across the medical community and across the country. But one standout issue that might resonate most in the months and years to come is how traditional fee-for-service payment models laid bare a crisis that keeps patients out of doctors’ offices and emergency rooms and puts a different kind of strain — financial — on the entire system.
athenahealth recently spoke with leaders about their approaches to value-based care (VBC), which emphasizes outcomes rather than volume. The trio shared their individual insights on the stages of their journeys and how the anomaly that is 2020 affects ongoing cultural, technical, and financial shifts that impact the health of their organizations and their patients.
Russell Baxley is the president and chief executive officer of Beaufort Memorial Hospital, a 197-bed system with an employed physician group of more than 100 providers. His organization is the early stages of value-based care initiatives and estimates that just 1 to 2 percent of revenue comes from such contracts.
Ed Corns is the senior vice president of physician services at Quorum Healthcare, which owns or operates 22 hospitals and 15 outpatient centers in 13 states spanning the South, Midwest, and West. Five to seven percent of revenue comes from VBC contracts, but Corns estimates that number will be 10 percent by the end of 2020.
John Donlan is the chief operating officer for Steward Health Care Network, an 11-state health system with 7,000 providers. The physician-led community-based accountable care organization began in Massachusetts, where they started pursuing value-based contracting as early as 2008. Today, those contracts bring in 95 percent of the revenue in Steward’s home state, while continued organizational expansion across the Northeast, South, and West is transforming myriad markets at different stages in their VBC journey.
How 2020 has affected momentum
Baxley: “While we were all talking about and wanting to move forward with value-based care, it was hard to put the financial resources forward to invest in the infrastructure to get there. Now I think everyone would say, ‘If COVID-19 is one pandemic and there’s thoughts that this may not be the only one in our future, we need to rapidly adopt changes in how we conduct business, continuing to prioritize patient-centered care in value-based models that focus on care outside of the hospital.’ I think [COVID] has really strengthened our vision. We’re using this as a springboard to push forward.” (Beaufort has a new patient-centered medical home initiative starting in January 2021 with Blue Cross/Blue Shield.).
Corns says he “defines a large component of value-based care as chronic care management (CCM)” and that Quorum has seen a surge in CCM enrollment in 2020 — particularly in rural markets. “In the COVID-19 era, where virtual care became a necessity, in terms of being able to be there for your patients, it made a huge difference in chronic care management enrollment. And we have benefited from patients wanting to have the ability to see our providers without having to physically visit the practice sites. CCM allows for a continual touchpoint with our practices and patients have responded favorably to the additional communication and care. We’ve clearly seen the writing on the wall, in terms of televisits in the standard evaluation and management path and in chronic care management.”
How to address 2020 reporting
This year, success can’t be measured in traditional ways and targets need to be readjusted.
Donlan credits the strength of Steward’s long-term relationships negotiating and working with payers and providers to help keep the “mission” of value-based care on track.
“We reached out to payers and said, ‘We need to think about measuring physicians differently this year. We need to think about measuring access and patient experience differently this year.’ If a member gets a survey that asks ‘How has your experience been in the waiting room?’ — and their last visits have been via telemedicine, there is a disconnect in the measure, right? For the large part, payers have been very collaborative. And we've come up with sort of creative and constructive ways to say, ‘OK, let’s treat this year differently.’”
Part of the performance realignment is organizational, too, continued Donlan. “We are also updating our own scorecards with physicians, and saying, ‘Listen, we went out with initial measures and targets for all of you. And we’re now going to put those specific targets on hold and pivot to measure progress. Let’s identify where there are gaps in care, either due to gaps in telemedicine access, or a shortage in PPE, or patient unwillingness or fear to engage with the healthcare community.’ We’ve pivoted away a bit from traditional measures this year and more toward efforts to navigate our way through the COVID crisis, such as ways to continue annual well visits and increase access to telemedicine visits.”
How telehealth is helping unite the continuum
Beaufort already had virtual care capabilities prior to COVID, and Quorum was able to easily transition to athenaTelehealth at the beginning of the pandemic. But Donlan says there is a “full spectrum” of where Steward physicians are with virtual care. Making sure they enable better access is now a higher priority on the value-based care roadmap — as is proper compensation for telemedicine to work. “We need now to move the financing mechanisms to align with the telemedicine needs. And there is always going to be a place for face-to-face visits with physicians. We’re committed to that. But the physicians need to be reimbursed fairly for telemedicine as we expand access. Thus far, Medicare, Medicaid, and other payers have been fully collaborative.”
How transitioning to more value-based care contracts may remove some of the traditional friction in healthcare
Donlan: “Historically, VBC been a win-win for the patients and the providers and the payers. We’ve seen improvements in the patient experience, that they're more likely to recommend a provider to a friend, that they feel listened to, that their needs are being addressed. We've helped them because we’re able to do some of the pre-visit planning for a large number of physicians and patients. And then, importantly, we've been able to do that while lowering the rate of inflation in healthcare. And that’s largely how we’re funded. We go into a deal, whether with the State of Massachusetts for Medicaid, or federal government for Medicare, we only can fund our operations if we’re improving quality and actually saving consumers and/or taxpayers money at the end of the day.”
On morale and motivation
Baxley says he isn’t yet aware of the full financial impact COVID-19 will have on Beaufort’s value-based care efforts, but the national “healthcare heroes” campaign had a positive impact on patient satisfaction scores and also boosted staff morale. Beaufort has used some of that positive energy to impact change in terms of how staff cares for patients in the hospital based on infection control concerns. “We have struggled, at times, maintaining the same levels of patient safety that we’re used to maintaining in the hospital, which affects penalties in the value-based care world. If you have 50 of your patients who are COVID-19 positive and PPE is in short supply, you try to limit your in-person exposure to those patients. So hourly face-to-face rounding becomes more difficult with these patients. With limited rounding, it is difficult to keep patient satisfaction scores up such as responsiveness of staff and help when pressing the call button. So while perceptions of hospitals and healthcare workers were more positive during the pandemic, certain areas of patient satisfaction were hard to maintain.”
As for Donlan, no matter at which stage various markets and physicians are at in their transition to VBC contracting, maintaining morale means providing the tools to eliminate some administrative burden. “Physicians are motivated by several things. Obviously, they want to drive the greater good, and aspire to be outstanding among their peers. But they also want to be fairly reimbursed. So we try to incentivize and support them with all three. You need to recognize their needs, give them the support that they need to reduce the hassle factor, all while trying to perform well on an increasing number of value-based care metrics required in the market.”
The importance of technology
Corns says chronic care management is set up as a partnered service at Quorum, and that athenahealth’s cloud-based system allows his team to enable remote access for who provide the services. It also means the organization can be more profitable. “We’re trying to figure out how we work with our population health nurses and our practices and our providers to engineer a kind of world to get to all of the available patients. Our CCM partners basically function as virtual members of the care team who has complete access to clinical records and complete access to communicate with the doctors and the folks in the practice. We’re seeing 30 to 40 percent of our population is enrolled in CCM. That’s good.”
Having the right technology in place across such a large and varied organization has been pivotal says Donlan; Steward moved a significant portion of practices to the same ambulatory EHR platform to optimize clinical and financial performance prior to the pandemic. “Given that such a large portion of our network is on athena, it’s allowed us to more easily integrate data. But it also helps with valuable referral management and direct booking processes. We have teams that identify quality gaps and care management needs. We identify over 300,000 individuals that need a specific care gap met. And the more we can identify that through electronic data feeds, and then telephonic outreach, and automatic booking, the more positive change we can affect.”
Advice for managing disparate cultures and steps in the transition “journey”
Steward is meeting people where they are in a different way, especially since 2017. It was then that the network acquired hospitals in Ohio, Pennsylvania, and Florida, and then shortly after, Texas, Louisiana, Utah, Arizona, and Arkansas, Donlan and his colleagues learned that the value-based care journey isn’t a one-size-fits-all solution given different organizational structures and regional cultures across markets.
“The original idea was to say, ‘Hey, we did this really well in Massachusetts. We’re going to go do what we did there, and plop it in these other markets.’ And then we quickly realized, it just doesn’t work that way,” he explained.
“And just as we say all politics is local, the healthcare value culture and the approach to it is local, because it’s largely a function of meeting both the payers and providers where they are. In some markets, many of the providers were still on paper medical records. Many had never been measured on quality or patient experience. They never received a score card. Many of our payer partners in these markets don’t have the infrastructure to actually administer value-based contracts. Many of us at Steward actually spent time on the payer side. So we’re coaching them through developing reporting, measuring quality, how to risk-adjust.”
As for where to start in a complicated landscape, Donlan suggests it’s about collaboration and organization. “It’s about getting the providers and the EHR community and the payer community together and saying, ‘How do we organize information in a meaningful way so that it can be reported on and acted on?’ And then, once the information is lined up, then you're in a position to transform the financing mechanisms, and then you're in a position to transform the culture..”