Health Care Leaders Highlight Collaborative, Patient-Focused Strategies for Advancing Value-Based Care

Health care leaders emphasized the need for collaboration, data standardization, and an iterative, patient-centric approach to advance value-based care (VBC) during a panel discussion at the Council for Affordable Quality Healthcare (CAQH) Connect 2024 in Washington, DC.

The discussion, titled “Value Based Care: The Next Evolution,” included panelists Todd Couts, MS, deputy director of the business services group at CMS; Michael Westover, MBA, vice president of data partnerships and informatics at Providence St. Joseph Health; and Amal Agarwal, DO, MBA, chief clinical officer at Monogram Health.

At CAQH Connect 2024, health care leaders discussed advancing value-based care through collaboration, data standardization, patient-centered approaches, and adaptable partnerships. | Image Credit: Chanelle Malambo/peopleimages.com - stock.adobe.com

Key Adoption and Administration Challenges

Moderator Kristine Burnaska, PhD, senior director of research and measurement at CAQH, began by asking Couts about the biggest challenges he has faced in the adoption and administration of VBC programs. Couts explained that he is part of the Center for Medicare and Medicaid Innovation (CMMI), or CMS’s innovation center, created from the Affordable Care Act. CMMI’s mission is to test models to find ways to reduce federal spending on health care programs while also improving the quality of care.

Based on his background, he identified 2 main challenges to adopting VBC programs: policy design and operational issues. Regarding policy design, Couts highlighted the temporary nature of CMS models, some of which only last 3 to 5 years before being discontinued if CMS decides not to make them permanent parts of Medicare or Medicaid. He noted that this uncertainty makes it difficult for providers to commit to long-term investments in these models.

Next, Couts criticized the financial design of the models, explaining that although they aim to partially reduce federal health care spending, they are primarily voluntary for providers. He noted that this creates a challenge when setting benchmarks and risk adjustments. CMS could design a model that cuts federal spending, but it may not be attractive to providers. Therefore, Couts argued that CMS must create a model that balances the reduction of federal costs with a structure that enables providers to succeed, which he described as “really tricky.”

The final policy design challenge Couts explored was overlapping models. CMS’ VBC models now cover 41 million beneficiaries and 314,000 providers. This allows it to target key areas but creates complexities for providers navigating the model landscape. To address this, he noted that CMS has been working to improve their communication and provide better clarity on each model.

Regarding operational challenges, Couts highlighted the need for rapid execution when implementing new CMS models, which typically take 9 to 10 months from clearance by the Office of Management and Budget to rollout. This requires CMS to quickly establish new IT, contracting, and payment systems. Additionally, adapting CMS processes to support data flows for attribution and benchmarking often requires workarounds or new setups, increasing the burden on providers. Couts said CMS is minimizing this by collaborating with other payers to align performance measurement and data formats, ensuring smoother multipayer integration.

Aligning Payers, Standardizing Data, and Enhancing Patient-Centric Care

Considering the challenges providers face with payer alignment and data standardization in VBC programs, Burnaska asked Westover which aspects of VBC need reconciliation between contracts. He began by describing the challenges his organization faced in managing these programs.

With 130 contracts, each with its own eligibility file, Westover noted that data came in many inconsistent formats, including delayed financial data and complex Excel sheets. This made it difficult to run an effective program, and, in one case, 8 staff members were needed to manually input clinical information, highlighting the model’s unsustainability.

He also pointed out that payers and providers have debated fee-for-service rates for decades. To improve their relationship, Westover suggested that both sides collaborate and focus on data-driven discussions to identify meaningful measures that benefit both parties and improve patient outcomes.

“I think if we can change the way that we think about health care together with payers, where we think about how we can partner together to do what’s best for our patient populations, reduce costs, and improve measurable quality, it can change the game,” Westover said.

Agarwal added that adopting VBC programs presents challenges to the provider workflow due to varying payer requirements. He noted that medical schools rarely teach clinicians to ask about patients’ insurance or benefits, complicating care delivery.

Also, Agarwal emphasized the importance of patient-centric approaches in population management. Whereas care typically begins when patients seek help, he proposed a shift toward proactive engagement, where providers reach out to patients in need of follow-up care. He noted that wait times can extend to 6 months, but by reaching out earlier, clinicians can make a significant impact.

“We have got to go to the patients, bring them in, and understand what’s important for them,” Agarwal said. “Then, we can design the right treatment pathways to keep people out of the hospital for avoidable hospitalizations.”

Continuing the discussion, Burnaska asked the panel for insights on the challenges of data quality and standardization in health care, as well as suggestions for improving collaboration between providers and payers to enhance care administration.

Westover suggested that payers and providers change their perspectives on VBC, approaching it as a partnership focused on improving patient outcomes and reducing costs rather than a hedge or bonus. By sharing comprehensive clinical and financial data in near real time, he argued that both parties can establish a shared understanding that enhances care delivery. Also, Westover emphasized that implementing standardized data practices, particularly in targeted areas with significant financial and patient impact, can lead to successful risk arrangements and scalability across different payers.

Couts followed up by discussing the data needed to administer CMS models. He reinforced Westover’s point, noting that VBC must evolve through improved data sharing between payers and providers.

“We don’t need perfect data, we just need timely data so an ACO [accountable care organization] that is managing a population has some inkling of an idea of, ‘Oh, there was an emergency department admission in my patient panel, I need to know about that,’” Couts said.

To address this, he explained that CMS is implementing pre-adjudicated claims data for real-time insights. It is also introducing a Fast Healthcare Interoperability Resources (FHIR) interface to streamline electronic health record (EHR) integration within the Enhancing Oncology Model; this will allow providers to focus on clinical workflows instead of manual data entry.

Streamlining Data and Advancing VBC With AI and Partnerships

Before addressing audience questions, Burnaska asked the panel how to modernize and streamline both data exchange and VBC overall. Agarwal began by suggesting 2 ideas. First, he proposed better leveraging of generative artificial intelligence within EHRs to extract and analyze data more effectively, especially in areas like diagnosis coding and social determinants of health. He explained that the current method of data documentation makes it challenging to derive actionable insights.

Agarwal also envisioned a future where patients have greater visibility and control over their health data, similar to how consumers access financial information and planning tools. He said this could empower patients to make more informed decisions about their care, helping them better understand their health output and quality of life.

Reiterating his earlier point, Westover emphasized the importance of payers and providers building strong, collaborative relationships to design VBC arrangements that benefit both parties. He suggested they focus on identifying shared goals and the data and resources needed to achieve them, rather than fixating on fee-for-service rate negotiations.

Westover provided an example of how Providence worked with a payer to standardize clinical quality exchange using FHIR, which significantly increased the data available to the payer and laid the groundwork for further collaboration on financial data sharing and beyond.

Couts then discussed CMS’s opportunity to leverage its influence and scale to drive data standardization, working alongside other government agencies and vendors. He highlighted how CMS engaged EHR vendors in an FHIR-based cancer data initiative by involving the Office of the National Coordinator for Health Information Technology, calling it a “perfect marriage within the federal government to really achieve a goal.”

Building VBC Without Consensus

The discussion concluded with a question from the audience on how VBC can be effectively built without consensus on quality measures and value definitions. Couts acknowledged that these issues are “wicked hard problems,” but emphasized the importance of transparency and collaboration in developing quality measures.

Within CMS, he said there is an ongoing effort to focus on outcome measures that matter, rather than relying on process-based measures. Couts also highlighted the advantage CMS has in testing models on a smaller scale before making them permanent, which allows for validation of the quality measures that most effectively improve outcomes before they are scaled more broadly.

Westover echoed Couts’ points, saying that although alignment on quality measures may not always be possible across all lines of business, payers and providers can still come together within specific lines to agree on a common set of measures to focus on.

Agarwal concluded the discussion by stressing the need for a partnership approach where payers and providers collaborate to identify the right clinical criteria and interventions. He also emphasized the importance of having the flexibility to iterate and adjust based on what proves most effective for their patient population.

“When managing populations...we should iterate together because as we care for people, we’ll discover what works and what doesn’t” he concluded. “I think it has to be a partnership. It can’t be a contract and walk away; it has to be a partnership.”