A panel of experts at the forefront of the value-based care (VBC) movement in Utah led a discussion on local advancements being made around its adoption at the 2023 Utah State of Reform Health Policy Conference last month.
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CMS has the goal of moving all Medicare beneficiaries and the majority of Medicaid enrollees into accountable care relationships by 2030, indicating the possibility of imposing a mandatory value-based purchasing model.
Based on the trends of the past decade, Utah and the nation are increasingly moving away from fee-for-service payments toward capitated payments, which is a sizeable transition operationally, financially, clinically, and culturally, according to Kate de Lisle, associate principal at Leavitt Partners, a Health Management Associates Company.
“We’re also seeing new organizations—new competitive threats to incumbents [who] are noticing this is the way the markets [are] heading,” de Lisle said. “How can we invest in value-based enablement, in delivery assets? We’re seeing large national payers all diversifying retailers that are investing and entering healthcare in new ways. And in conversations we have with health system executives and other incumbent organizations, those competitive threats are causing groups to take value seriously as a strategic competitive priority.”
She said VBC requires fierce commitment from senior leadership and substantial capital investments to change existing business models. The panel highlighted the efforts of the One Utah Health Collaborative, which is working with state partners and stakeholders on improving patient outcomes and reducing costs through value-based innovation.
The collaborative is in the midst of forming an Innovation Advisory Committee, which is scheduled to be finalized in June, to review community submissions and prioritize support for initiatives impacting primary and behavioral healthcare, electronic health information (EHI), and health insurance coverage.
The Utah Legislature passed Medicaid reforms this year associated with the collaborative’s work—an extension of postpartum coverage from 60 days to 12 months and eligibility expansion for family planning services, CHIP coverage for children without citizenship, and preventive care and dental services for adults.
Local provider Revere Health is one of the early adopters of VBC in the state, adopting its model in 2010. The organization’s CEO Scott Barlow spoke about the upside that the transition has had in its operations.
“We do detailed cost accounting for our physicians, so [that] all of our physicians have their own financial statement,” Barlow said. “What that’s done for us over the years has extended to cultivate a culture of innovation, entrepreneurialism, and trying to find ways to make [care] better, and a lot of natural alignment of consequences of choices. And so we’ve always been an experimenter of faster, better, more effective ways and have absorbed the lumps of that experimentation at times and have found successes.”
Barlow highlighted the difficulty for its providers to standardize processes as one downside of the model but reported that the early adoption of its electronic health record (EHR) system in 2005 has led to advancements in EHI exchange.
Revere Health’s EHR system has evolved into a sophisticated point-of-care tool where it can digest data in real-time from hospital partners, carriers, and historical data sets that enable its clinicians with the necessary information to diagnose and treat.
“We spend more of our time on logistics of trying to make it happen and less trying to just know what’s supposed to be taking place—that’s been quite helpful for us,” Barlow said. “That’s also been a tool that we’ve been able to use and learn from across the country. When Medicare started [its] Meaningful Use program, our tool worked fairly well for that and we became part of the quality [clinical] data registry for Medicare—we have about 360 groups across the country that [utilize] our tool sets on their electronic record system.”
Barlow said the work on patient de-identified data extraction is leading to more effective technology and insights on creating best practices for VBC.
Ezra Segura, market president of Aledade, the largest network of independent primary care in the country, spoke to the organization’s growing presence and efforts to expand VBC in Utah.
“Moving from quantity to quality is really how Aledade approaches our work with physician practices in terms of access—evening hours, weekend hours, availability to get in for urgent needs, reducing hospitalizations, educating patients, and managing transitions of care,” Segura said. “We need hospitals, we need imaging centers, we need all of these resources that are available to us, but we need to be able to [access information] seamlessly.”
Segura said Aledade’s VBC contracting is about ensuring the accountability and financial sustainability of independent practices through support for improving outcomes and reducing costs over time.
Castell Health, a subsidiary of Intermountain Healthcare that manages the latter’s population health platform, said its value-based contracts encompass more than one million patients, mostly in Utah, with a total cost of care of about $4 million. Ensuring multi-payer engagement is important to achieving the “disruptive innovation” of VBC, said Eric Cragun, executive director of government programs at Castell Health.
“We have contracts across Medicare, Medicaid, with commercial payers, with employers,” Cragun said. “It helps to have more of the revenue, more of the patients that we’re seeing under these value-based contracts that we can really disrupt the way that we’re delivering care. Castell, through the contracts that we secure with payers, is able to offer a number of services that in a fee-for-service world wouldn’t really be financially sustainable.”
These include care coordination and management where non-clinicians conduct outreach and follow-up with patients to conduct annual wellness visits and evaluate social determinants of health. Castell is identifying patients at risk of food insecurity who cannot access nutritious meals, and connecting them with community-based organizations to address those needs.
“We think that for our providers, the more patients on their panel who can be in these [VBC] arrangements, the better,” Cragun said. “We tried to move as many of our contracts into value-based care arrangements—we’ve tried to set things up so that our providers don’t have to think about which of their patients are in a [VBC] arrangement versus which patients aren’t and wouldn’t get [services]. And so we’re trying to be really seamless and streamline for our providers their data tools.”
Ultimately, the fundamental need driving the efforts to transform the health delivery system from fee-for-service to value is the system itself.
“There are these mounting economic pressures at the state and federal levels for consumers and families, for employers—it’s really just a burden that must be addressed,” de Lisle said. “So that financial imperative to change is certainly the biggest driver, but there are others.
Demographic changes—we often talk about the baby boomer population aging into Medicare. At the same time, we also are facing projected and current workforce shortages. How can we care for an increasingly old, sick, and longer-living population with fewer resources in a way that’s going to be cost-effective and sustainable?”