Health system complexity, market forces, and infrastructure needs are barriers to more value-based care in Utah, experts say


Maddie McCarthy


Health leaders discussed value-based care at the 2024 Utah State of Reform Health Policy Conference in March.

John Poelman, director of innovation at the One Utah Health Collaborative, discussed state and national initiatives to help Utah move toward more value-based care. 

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Senate Bill 126, which passed in the legislature in 2023, called for the incorporation of quality measures outlined by the Centers for Medicare and Medicaid Services (CMS) into hospitals, Poelman said. He highlighted conversations he’s had around certain alternative payment models (APMs). The collaborative is helping to conduct an assessment of an APM—CMS’ All-Payer Health Equity Approaches and Development (AHEAD) model.

“This is a Medicare, Medicaid, and commercial-aligned model where you get hospital global payments, [an] advanced primary care model, and a series of total cost of care targets,” Poelman said.

At the national level, Medicare continues to consider value-based care. Poelman said Medicare has a goal of getting all its beneficiaries in care relationships with accountability for quality in total healthcare costs by 2030.

“Medicare continues to think about how they drive the system,” Poelman said. “They have evolved in their thinking and it’s not just Medicare—they want Medicaid to align in payments, [and] they want commercial [insurers] to align in payments. You’ve seen a lot of their models trying to encourage total cost of care.”

Dr. Peter Weir, chief population health officer at University of Utah Health, said a major barrier to value-based care is market forces. 

The payer mix in Utah is very different compared to other states, Weir said, citing statistics from KFF. Utah has the highest percentage of people covered by employer-based insurance, the second-highest percentage of people covered by non-group insurance, the smallest percentage of people covered by Medicaid, and the second-smallest percentage of people covered by Medicare. 

“I think the pressures to do value-based care come from government-based insurance,” Weir said. “In states like New York, New Mexico, and others, they’re steep in this stuff. Why? They have to be.”

Eight years ago, Weir helped create the university’s Intensive Outpatient Clinic (IOC). IOC serves high-risk Medicaid members. 

“We’ve been able to create a sustainable model [in IOC] by demonstrating to our managed care organization that runs Healthy U Medicaid and Health Choice Utah Medicaid that we can reduce costs through reducing hospitalizations and emergency room visits among a very high-need, high-risk population of Medicaid members,” Weir said.

Weir said there is an opportunity to work on value-based care within the Medicaid space, and Medicaid leaders in Utah are willing to work with healthcare organizations. 

Dr. Sarah Woolsey, medical director at the Association for Utah Community Health, discussed community health centers and their role in value-based care. She said they were created in the 1960s during the “war on poverty” to address health inequity.

“In terms of value, that original idea is that health was available, accessible, and affordable in communities, which leads to health,” Woolsey said. “So in terms of participation in value appraisal at [established] health centers, they’re an ideal model. They’re also naturally addressing barriers [like social determinants of health].”

Utah has 14 community health centers, which operate clinics throughout the state. Woolsey said the centers are thriving, despite being small and facing the need to provide more documentation on quality measures. But clinics looking to change to a value-based payment model face a lot of initial challenges, Woolsey said.

“In looking at health centers adopting this new payment structure, it requires data infrastructure, panel management, [and] it requires that transition of care management. All of those elements are fairly administratively heavy, and when they’re really looking to care for patients on the front line, that infrastructure is hard to build. So without upfront support, I would guess it would be harder for them to do that effectively.”

— Woolsey

Andrew Croshaw, CEO of Families First Pediatrics, said he wants his organization to work with payers to continue to advance value-based care. Families First Pediatrics utilizes integrated healthcare, a model that is highly emphasized in value-based care. 

The clinic combines medical, dental, orthodontic, and mental healthcare in one place, which Croshaw said allows for better health outcomes because all the services are under one roof. 

“Castell is a third party that is measuring a whole bunch of outcomes and activities across [our] system, and we’re performing very well on (the) reduction of hospitalization, (and the) reduction in emergency department use due to behavioral health, vaccination rates, [and] rates of screening for mental health,” Croshaw said.

Another barrier to value-based care is system changes and complexity, Croshaw said. He added that some payers are interested in working with providers to administer value-based care, but it can be inordinately complex.

One option that could help improve and streamline value-based care is the use of clinically integrated networks (CINs), Croshaw said.

“We have two CINs that have approached us who basically say, ‘We want to sign up a whole bunch of providers, and then go negotiate with payers on behalf of those providers [as to] what the measurements of population health and quality will be.’ And essentially what you’re doing is creating a scale partner because payers are at scale and providers are not. They’re diffuse. By aggregating providers underneath a CIN and then going to a payer, you get more homogeneity in the expectations of payers.”

— Croshaw

Croshaw said smaller organizations may have a harder time moving toward value-based care due to infrastructure and investment needs.

Due to a general lack of large employers in Utah, smaller employers need to partner with each other to affect change and incentivize value-based care, Weir said. He added that if clinics begin to implement a value-based care model, they need to ensure they have a payment model that reflects it. 

“What I see are often models that are part way there, and it creates a lot of undue stress for certain team members, including physicians,” Weir said.

Woolsey said payer and quality measure alignment needs to occur in order to promote more value-based care.

“If we can get more alignment in the hodgepodge of payers, it will make a difference to small practices,” Woolsey said. “If we can get alignment in the quality targets, the outcome targets we’re looking for, and work together in that area, it will make a difference to that frontline delivery.”

Poelman said the promotion of value-based care depends on leaders who are willing to make changes. These leaders need support, he said.

Croshaw said change in the value-based care landscape will come in unexpected and large ways based on a variety of factors, including election outcomes and the country’s financial situation.

“If rates continue to go up, I think it’s going to precipitate big changes in how much we can afford to pay benefits in this country, which is going to hasten opportunities to interact in more comprehensive, value-based ways because we’ll be kind of forced into it,” Croshaw said.

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