A Feb. 24 discussion among hospital system executives at the Value-Based Payment Summit focused on the challenges and opportunities they face in transitioning to value-based care. They discussed barriers such as data management, infrastructure costs, and risk adjustment methodologies, as well as where they expect to focus their efforts in the future.
Rural hospitals can have unique challenges adopting value-based programs, explained Julie Yaroch, D.O., president of ProMedica Charles and Virginia Hickman Hospital in in Lenawee County, Michigan. Many of these models require the same information, but they have different definitions and different exclusion criteria, and different time frames, she said. “Not all of this data can be pushed electronically. A lot of it is manual. Being a smaller hospital, I also have low volumes in some of the metrics, so therefore I can’t meet the threshold.”
Yaroch also raised the issue of risk adjustment methodology. “Does that fully account for clinical complexity and severity? It’s not just about making a diagnosis and choosing the right lab or the right procedure. There’s so much more that goes into the care. We need to start looking at the complexity a patient brings,” she said.
Stephen J. LeBlanc, chief strategy officer for Dartmouth Health system in New Hampshire, stressed that value-based payment plan goals are usually very consistent with the health system’s mission. “We don’t want patients to have to show up at our EDs because their chronic disease isn’t being managed or needing to be admitted when it could be prevented,” he said. “But it’s the execution that’s the challenge, right? It’s the investment in the infrastructure. It’s very important in our organization that we don’t set up programs that are just geared toward patients who are under these value-based arrangements. We want to provide those services to all of our patients, so that increases the cost of the infrastructure, because you want to use those processes across all of the patients.”
LeBlanc spoke about facing challenges with multiple contracts with different measures, different ways of measuring the same kinds of performance data. “We ended up just saying we’re not going to chase every measure. We’re going to pick five or six of the same measures across the entire patient population. It is much easier for our providers and our reporting and analytics teams.”
Dartmouth Health also has seen some challenges with the insurance companies it works with hiring their own care management companies at the same time the health system is trying to do work with the patients, which can lead to confusion around that data. “It is always a big challenge getting data on time in a usable format and then being able to do the analytics on all of that as well,” he said. “I think sometimes when we’re dealing with large payers, they have kind of a one-size-fits-all model, and that doesn’t always work, depending on the market or the geography that you’re in.”
LeBlanc echoed some of the points made by Yaroch that in rural areas, they don’t have post-acute care services that are staffed well, due to workforce shortages. “We have transportation issues., so we don’t always have a place that we can get the patient to in a timely way,” he added. “We’re struggling through that. We’re struggling through certain cost targets and the methodologies and the attribution methodologies, where we find out we’re being held accountable for patients who we’ve never seen before, never met before. So I think all of that needs to get sorted out as we go.”
Taking advantage of Cleveland Clinic’s scale
Commenting on the data challenges, Wesley Wolfe, M.H.A., vice president of payment and network strategy, at Cleveland Clinic, said his organization is fortunate to have enough scale to be able to do a lot of reporting. “But at times, we have had to use that scale to force some consistency across some contracts around measures or time frames, just so that we can do that without having to continually add resources for a one-off measurement contract somewhere. What we’re trying to do is ask: Does this work at scale? And there has to be some consistency to that.”
One issue is the timing of the investment versus the payback rate, Wolfe said. “It’s one thing if you’re in a capitated model, and you’ve got some resources coming in, you can start to peel off a portion of that capitation and then deploy that towards infrastructure needs as you go,” he said. It’s a very different thing to have those same infrastructure needs, and then run a measurement period of 12 months and a six- to nine-month run-out period, and then another three- to six-month reconciliation period in hopes that you’re going to have something left at the end, when at that point you’re now roughly 24 months into investment in the infrastructure. That’s much more difficult sell when I go to my executive team.”
The panelists were asked to turn from challenges to the opportunities they see in value-based care. Cleveland Clinic’s Wolfe mentioned taking lessons learned and infrastructure developed for Medicare Advantage into Medicaid managed care.
“It’s unlikely that we will ever, at least in Northeast Ohio, move out of the fee-for-service business. There are just too many patients that travel in from around the state or region or from around the country for us to cover everyone in capitation,” Wolfe said. “So we will likely be living in in both worlds — maybe forever. But our strategy is to move forward in the over-65 area developing skills and programs that we can then apply to other populations. They won’t be identical, by any stretch, but as the largest provider of of Medicaid by volume in the State of Ohio, we think there are real opportunities once we get our feet better underneath us, to start to look at the Medicaid population and think, OK, what is transferable from the over-65 to that Medicaid population, and what can be done better? What infrastructure can we build now that we can simply scale and not have to reinvent the wheel, as we move into Medicaid?”
A team game
Dartmouth Health’s LeBlanc said that among the bigger opportunities he sees involve providing more of the care patients need outside the walls of its hospitals. “The remote patient monitoring and hospital-at- home type initiatives are going to grow,” he added. I think they’re a little bit challenging to do those in some geographies, so we’ve got to figure that piece of it out. Most of our contracts are total-cost-of-care contracts. I worry in some of the geographies, we have, some hospitals that are independent, and they’re reticent to take on risk because they’re working at really small margins. And oftentimes, there are parts of utilization you can control and parts you can’t. Providers aren’t built as insurance companies with risk-based capital and so forth. So we have to figure out how to be more innovative around the kinds of models in value-based care.”
LeBlanc said he takes a step back and thinks about fee for service and value-based care, by looking at the services that Dartmouth provides. “I say, well, trauma probably should be fee for service. And we should have surgical bundles, and maybe for chronic disease and primary care, you have capitation. So I think there’s a mix of models that we haven’t quite figured out how to blend, and we pull them all together in a total cost of care, and it can be challenging,” he said. “I’m really hoping to see more partnerships between insurers and providers, testing different models in different geographies to see how those work. But we have to keep patients healthier to get the cost of healthcare down. We’re not going to do it just on cuts and reducing prices. It’s going to be a team game.”
Yaroch says that in the future she would hope to be able to look at how these programs tell a story that drive action plans to build healthier communities across the nation. “How we can continue to share ideas about how these programs also can drive better patient engagement? I think it’s really helped us with a team engagement model, but there’s still that patient aspect. If these programs can somehow also push patient engagement, then together we can move the needle faster and farther to improve our communities,” she said.
The things that Yaroch hopes to see are size-specific programs that enable all of us to participate. She also mentioned the idea of a centralized data repository, to decrease the workload on providers, standardized definitions of the metrics so it’s less labor-intensive for smaller hospitals, so that it’s easier for them to participate.
