Primary care doctors: The ‘quarterbacks’ in a value-based care playbook

The journey to value-based care, an alternative health care model in which doctors are paid based on the health outcomes of their patients, begins with the primary care physician.

“There is no question in my mind as it relates to the importance of the primary care doctor as the quarterback of patient care in any type of value-based model,” said Kamal Jemmoua, CEO of Prominence Health, the value-based division of Universal Health Services. ”But as we advance and see the maturation of the work we are doing in value-based care, we would be remiss if we didn’t recognize that there are deep needs to engage specialists around condition-specific management.”

Jemmoua shared his insights during “Using Data to Improve Provider Referrals and Increase Savings,” a webinar sponsored by CareJourney and Fierce Healthcare.

Aneesh Chopra, president and cofounder of CareJourney, agreed that provider referral management can have a significant impact on value-based care program costs. Approximately one in 20 primary care office visits results in a specialist referral, with the largest share (45%) made to surgical specialists. Encouraging informed referrals to specialists who demonstrate lower costs and better outcomes can have a significant impact on value-based care program costs — in some cases, resulting in millions of dollars of annual savings.

But changing provider referral practices can be difficult, and many physicians still lack access to specialist performance insights for multiple care episodes that can help them make informed referrals. Affordable Care Act data on Medicare, Medicare Advantage and Medicaid can provide important insights.

“Everything harkens back to the ACA in the delivery reform discussion,” he said. “We are about a decade after the passage of the ACA but are having a conversation that has its anchoring in the ACA. Section 10332 asked for the release of Medicare data for the purpose of provider performance measurement. A decision was made that we would have a more open marketplace for provider performance measurement.”

The objective was to make this performance data available for public use.

“That may take the form of health plans integrating this information with their internal claims data to have a higher data set on which to make judgments,” Chopra said. “It may be health systems and provider networks taking this on their own, but it’s an open opportunity to access Medicare, Medicaid and Medicare Advantage for the purpose of provider performance management.”

The Center for Medicare and Medicaid Innovation published a strategy document outlining the goal of having 100% of recipients who currently are in traditional Medicare and the vast majority of Medicaid Advantage participants to be in accountable care relationships by 2030.

“It is critical to note that the primary care entities are expected to coordinate or fully integrate with specialty care,” he said. “That bridge from primary care to specialty care is now front and center. The objective is to move toward a world where all conditions can be more properly allocated in terms of either a primary care-only relationship or a shared-team relationship.

“So this decade of the ACA has three flavors – release the data so we can grade performance, integrate this in a move to value-based care and operationalize it to strengthen the handshake between primary care physicians and specialists.”

Prominence Health has embraced value-based care with integrated delivery systems between primary care physicians and specialists.

Related: Advancing value-based care: AMA, AHIP and NAACOS team up to launch new playbook

“We developed a program where we centralized all of our referrals from our primary care physicians to our specialists,” Jemmoua said. “Patients have conditions that we need to manage better. It starts with the right quarterback and then where we are sending patients for deeper specialty care.”

The results so far have been impressive:

• Membership has grown by 77% in four years because of strategic product and operational changes.
• Accountable Care Organizations have saved $375 million on Medicare, which they were able to share with participating providers.
• Medicare plans have improved and received four-star ratings.
• Exceptional health services and positive patient outcomes have earned an average quality score of more than 94%.

“The great news is that, as we have engaged in this work, the physicians that are in the markets are very willing to engage with us, in part because they all buy in to the ultimate cause: We all want to figure out how to change how patients are managed,” he said.