Equity was at the forefront of Reuters’ value-based health conference in Philadelphia last month. Over two days, executives from accountable care organizations, health systems and payers spoke about interoperability, population health, social determinants, the cost of care and taking on risk.
Across the board, speakers agreed that the transition to value-based care (VBC) is both inevitable and critical to improving the healthcare system. While to date, adoption of VBC has been relatively slow, some predicted that is soon to change, spurred on by federal efforts.
“Things take longer to happen than you think they will, and then they happen faster than you thought they could,” Don Calcagno, chief population health officer at Advocate Health, said in his presentation, quoting an economist. “He is spot on.”
Here are Fierce Healthcare’s biggest takeaways from the event.
Balancing fee-for-service and risk
Payers are increasingly vertically integrating and acquiring physician groups. In fact, Optum Health is one of the country’s largest employers of physicians. At the same time, more providers are interested in taking on risk in value-based arrangements. A sustainable economic approach to fund such efforts, Calcagno argued, is a "payvidership" model.
The traditional healthcare value chain is highly fragmented. Attempts to innovate within a flawed framework can be harmful, Calcagno cautioned: “If you optimize a sub-process, you suboptimize the system.” Suboptimization also invites disrupters in, who “suboptimize the whole system even worse.” Payviders can help bridge gaps and minimize duplicative efforts along the way, saving on costs and improving health outcomes.
Since the merger between Advocate Aurora Health and Atrium Health, Advocate Health now serves nearly 6 million unique patients. The health system manages 2.3 million value-based lives and has paid out $1.25 billion in value payments.
Calcagno believes it is possible to do both fee-for-service and VBC. “Even if we do value perfectly, we’re still going to have volume, so it’s about doing the right volume,” he said. "It’s like a stock portfolio with equity and bonds: there are lower highs and higher lows. When your hospitals are empty and you’re capitated, you make more money. When they’re full, you make less. But together, there’s a balance."
Others took a more binary view of the need for VBC. “When you are accountable for the quality and cost of the whole population, now you have a very strong incentive to look at the population,” Mohamed Diab, CEO of the CVS Health Accountable Care Organization (ACO), said in a panel on disparities. "That pushes you to see what else is going on, what are the barriers of care for this human being? You develop this person-centric approach."
'Parallel tracks' of data and the need for partnerships
Payers have traditionally had large sets of data, while providers have been less systematic in their data collection. In effect, each party has been collecting their own siloed data and providing their own solutions from their respective vantage points.
“There are kind of these two parallel tracks,” said Alex Ding, M.D., associate vice president of physician strategy at Humana, “which to me is really a duplicated effort.” Standardization and integration can help drive partnerships between payers and providers and community-based organizations (CBOs).
Ding sat on a panel alongside executives from UnitedHealthcare and UPMC, moderated by Fierce Healthcare's senior editor Paige Minemyer. They stressed that raw data are not useful or usable, and it takes bidirectional communication to figure out their limitations. Interoperability enables CBOs, which don’t have electronic health record software like providers, to plug data into a platform of their choosing that works best for them.
“Without good data, we’re essentially trying to do population health, population management, by anecdote—and I think we all know that simply doesn’t work,” said Matthew Hurford, M.D., VP of behavioral health at UPMC.
And payers should be asking for population health data from different places and in different ways than they have historically done, like claims, Hurford added. “If we restrict ourselves to where we have got some illumination, then we’re missing out on understanding so much more,” he said.
Engaging community partners
Kaiser Permanente identifies community needs not only by collecting data from state and national sources but, importantly, by engaging with community partners. “That’s actually what’s moved us further and further upstream,” said Anand Shah, M.D., Kaiser’s VP of social health. Discovering that many underlying issues are related to the social determinants is “what’s driven us as an organization to say we must invest and think differently," he noted.
One of the greatest opportunities for healthcare stakeholders is to leverage insights from communities to shine a light on gaps and disparities. “For this work to meet its goal, we have to be able to reach deeper into our communities and ensure that they feel comfortable,” Shah stressed.
The payvider has 12.3 million members covered under its plans, nearly 8 million of whom have at least one social risk factor and more than 4 million of whom desire assistance. It connects members to resources through Thrive Local, a social health network with an online directory of CBOs and services. The tool, powered by Unite Us, offers providers real-time status updates on referrals. Kaiser has 7,500 CBOs in its network, which, in 2019, it called the "most comprehensive, far-reaching social health network of its kind.”
Helping CBOs set up data infrastructure is really important, but it’s also important to support the practices that go with good data management, Hurford of UPMC said. That could mean having a learning collaborative around how to use a patient registry—helping CBOs understand not just how to import data, but how to turn the information into an actionable population health strategy.
“We set ourselves up for failure if we think this is simply a technology problem. It is not,” Hurford said.
Looking at health through the lens of equity
It’s critical to center equity in all efforts, speakers said in a panel on addressing disparities.* The clinical parts of a person’s care are just pieces in the larger picture of their life. Thus, taking a person-centric approach to understand the barriers of care and social determinants is the only way to truly address systemic disparities.
“Healthcare redesign requires us to move toward, or integrate and expand, a prevention model,” said Jennifer Mieres, M.D., chief diversity and inclusion officer of population health at Northwell.
The health system has established health equity teams in each of its clinical departments, which has enabled a systematic review of care gaps that has driven smarter interventions and better outcomes for patients, Mieres said. Northwell also has a community and population health department that works with CBOs to figure out local needs. A lot of those include food insecurity and legal help.
Similarly, CVS Health has invested millions of dollars in affordable housing as well as transportation and food. “This is hard work and requires a lot of investment,” Diab said, along with the right data collection and intervention design. CVS Health ACO is currently trying to incentivize physicians to collect SDOH data with a financial reward, Diab said. Then, an analytics tool predicts risk and suggests interventions.
Managing patients upstream in the most efficient setting, like at home or virtually, is one of the primary lessons of value-based care, executives said during the conference. CVS Health ACO deploys multidisciplinary care teams that go into at-risk patients’ homes. The organization also leverages CVS’s retail footprint as another way of filling gaps in care. “These retail clinics become part of this clinically integrated network,” Diab said.
*Fierce Healthcare's Anastassia Gliadkovskaya moderated the panel.