Speaker series: Value-Based Care 101

An emerging class of tech-enabled providers are poised to support a breakthrough in the healthcare industry. This, among several other converging factors, has led to Value-Based Care (VBC) gaining traction. It has the potential for huge cost savings for providers and better outcomes for patients; however, the system is complex and change is difficult. 

Capable Health invited expert Jay Knowlton, MPH who leads VBC products at Quartet Health to have a conversation on the Value-Based Care model and its role in the changing healthcare landscape. Quartet is a company that works with health plans, systems and provider groups to deliver speed to quality behavioral health care for all. Jay is driven by reforming health economics in the U.S. to improve patient outcomes — in part, by enabling value based mental health programs. 

Why we need Value-Based Care

In the context of where the U.S. sits compared to other developed countries, the healthcare system falls short in many key categories despite spending more money per capita. Life expectancy, infant mortality, obesity, and diabetes rates – all demonstrate worse outcomes. 

In short, Americans are not getting what they pay for. Jay’s theory is that while the U.S. far outpaces other countries on health spending, it falls behind on social service spending. When a VBC model is introduced, businesses like Quartet can quantify upstream investments that will avoid downstream costs, wherein providers are engaging people in their health and wellness. Getting paid based on the volume and complexity of care instead of on whole health and wellness will be a thing of the past.

Value-Based Care design & evolution 

The landscape as seen today has been ten years in the making. Programs from the Center of Medicare and Medicaid Innovation (CMMI) have crafted new and standardized measurement and payment designs that are based on capturing and quantifying investments into specific patient populations. 

One way they have accomplished this is by pushing insurance risk out of the insurance company and into the hands of providers. Commercial health plans are starting to adopt similar programs and are even taking it a step further with risk capitation. Risk capitation refers to a payment model in which private insurance companies and/or Medicare partner with healthcare providers, then transfer all financial risk for patients' care to those providers. With Medicare and Medicaid and commercial health plans getting involved, provider groups need to align themselves with this emerging mode of care delivery. 

Providers within a VBC model are incentivized to keep patients healthy in the long-run, as opposed to the traditional model of treating the patient immediately in front of them and running up the tab of services because they are now on the risk-bearing end of patient care. They are looking at comorbidity scores, the total cost of care per member per month on a total population basis, where patients are receiving services, among others. 

Managing whole health

A key consideration of managing whole health is managing total cost of care by engaging with people and keeping them out of the hospital. If patients do end up requiring acute treatment, providers must follow up and ensure they are equipped with the things they need to avoid readmission. 

There is usually a small percentage of a given population that is driving an enormous percentage of the total cost. Through data, providers can determine which levers to pull to engage with that part of the population and direct the resources to the patients that need it the most. 

The industry is seeing considerable consolidation of healthcare systems to create a shared data ecosystem. This enables better coordination of care and providers can refer to themselves. This, along with using standardized, clinically validated assessment and screening tools, means patients can be treated with more effective care plans to show improvement over time. 

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How digital solutions fit into Value-Based Care

Healthcare technology can play a big role in easing the transition to a Value-Based Care model. Market forces from the shift of risk necessitate solutions that will improve provider capabilities and patient engagement. 

One example Jay called out is health plan enablement. Technology solutions can enable which percent of their members they can offload the risk for and in which ways as well as guide risk stratification and patient outcome attribution.  

On the provider side, VBC rewards proactive engagement that is enabled through digital solutions. Practitioner dashboards can paint a much clearer picture of patients. They can be used to unlock patients that aren’t engaged with their care or uncover unmanaged conditions, behavioral or otherwise, that are causing certain parts of the population to drive up the total cost of care. Logic-based digital engagement like automated workflows can also help surface issues before they become more complex and costly. This makes it so patients are not consuming additional healthcare resources that don’t need to be consumed in order to drive the right outcomes. 

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Where does VBC still need solutions?

One day there might be a world where all provider groups, health plans, and payers prioritize longitudinal, whole health care. However, surgery procedures and other services rendered are still a source of revenue in today’s system. Until VBC is fully embraced, it’s up to providers to bridge these competing incentives. 

There will need to be a big enough risk pool so that there is room for a short-term increase in costs, which will be made up in the long-term cost savings. Providers will need to look at sophisticated actuarial data to show what the total cost of care would have been without proactive engagement. 

Additionally, as with all things, widespread Value-Based Care implementation will need checks and balances. Insurance companies cannot be allowed to have a disproportionate amount of negotiating power. There will also need to be checks on preventing patients from being engaged from too many angles to prevent fatigue. 

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How Capable powers Value-Based Care

For VBC to succeed, providers must engage with their attributed populations. Unlike legacy EHRs, Capable’s platform powers Value Based Care. With out-of-the-box automation of manual work and increased patient accountability, we allow healthcare organizations to serve larger patient populations with fewer resources.

Want to discover the suite of care management tools designed to lower the cost of care delivery through improved patient engagement? Chat with our team today.