Value-based models for primary care
Primary care providers are best positioned to lead the shift away from fee-for-service and change the trajectory of patient outcomes.
Employers face a daunting challenge recruiting and retaining talent. To compete for talent, offering quality health care benefits is without a doubt essential. Yet, the cost of health care for employers continues its relentless increase: HR consultancy Mercer’s Survey of Employer-Sponsored Health Plans 2021 projects a premium increase figure at 4.7% for 2022, based on 1,502 employer responses since mid-June. Employers are juggling offering high-quality benefits to attract and retain top talent while reducing or stabilizing total costs. Value-based care is increasingly the answer to quality of care, optimization of the health of workforces, and lowering costs for payers.
The problem is simple: fee-for-service models are in conflict with delivering quality health care and the ongoing optimal management of chronic conditions. The fee-for-service model incentivizes the quantity of services rendered and disincentivizes preventive care. In contrast, value-based care incentivizes providers to leverage underlying clinical and social determinants of health data to prioritize care and intervene early. In doing so, providers are able to steer patients to the most effective treatment options or specialists, lessening, mitigating, and preventing advancing chronic or more severe conditions from taking hold.
Until recently, value-based models were harder to adopt by large numbers of providers – and the largest segment of providers is primary care physicians (PCPs); the providers on the frontlines. PCPs are best positioned to change the trajectory of patient outcomes because they are able to decipher the earliest indicators of deteriorating health. While the data supports enormous benefits to payers and patient outcomes, the challenge in adoption has always been the realignment of financial incentives and focus on long-term outcomes.
Health care models are advancing through technology
In value-based models, PCPs are rewarded with partially or fully capitated business models, receiving a risk-adjusted per member per month payment. The benefit to the patient is treatment programming is aligned with prevention and early interventions. The benefit to the payer is decreased costs associated with urgent and crisis-level emergency interventions. Yet, accomplishing these objectives at scale is complex and requires the adoption of more advanced technology.
To change course on models, payers and providers require fully integrated analytics, population health management, and administrative capabilities to enable the opportunity of value-based care. PCPs and payers cannot evaluate success in the dark; they need deep analytics and critical management to support oversight and administration of payments. The options, however, to manage value-based care and patient outcomes through technology have been limited and deeply challenging. Most PCPs have struggled through three to five-point solutions, with different data definitions across persistently siloed systems and processes. The result has been disconnected patient information, blind spots, and disjointed reporting.
Today, however, payers and providers alike can benefit from comprehensive data, analytics, and reporting supporting both the direct care initiatives and business operations for success. Today’s new and advanced integrated platforms create accessibility to critical, homogenized, and discoverable patient data. Providers benefit from more concise insights enabling more precision in diagnostics. Further, through integrated platforms, the administration of claims is streamlined with a capitation engine, eliminating the complex management of payments.
Self-funded employers, benefits professionals, and PCPs can collaborate to improve quality, reduce costs and drive patient outcomes. By moving to a value-based care model led by PCPs, employees benefit from early detections and interventions embedded in their care as referrals can thwart chronic or escalating conditions to specialists and ongoing monitoring.
With the cost of health care rising and national health spending predicted to grow to $6.2 trillion by 2028, the price of services will only accelerate. By focusing on in-depth patient engagement and preventative care, payers can impact and decrease costs, increase the productivity of their workforces, and offer a benefit that stands out to prospective employees in a highly competitive talent market.
David B. Snow, Jr. is chairman and CEO of Cedar Gate Technologies.
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