Transitioning from FFS to Value-Based Care: A CMO’s Journey

Organizing ambulatory care in a way that facilitates success in value-based contracts presents both significant opportunities and challenges. No one knows this better than Dr. John Farley. Dr. Farley, an internist who has practiced in Birmingham, Alabama, for nearly 30 years, has come to realize that, in his words, “the fee-for-service model of care is like a treadmill” for primary care physicians, who struggle to consistently deliver enough treatment volume to generate high margins during times of high costs and high patient utilization. Farley managed a 17-physician practice in Birmingham until five years ago when he sold it to Complete Health, a company that manages and finances primary care practices and includes more than 150 physicians, and became chief medical officer of Complete Health. Complete Health is based in Jacksonville, Florida, and operates clinics in Dayton Beach, Florida, Richmond, Virginia, and Birmingham.

The company’s website states: “As a physician-led, patient-centered primary care group, Complete Health differentiates itself by offering services designed to make your life easier, including specialized senior programs. Complete Health focuses on personalized health care that is tailored specifically to you. As a value-based health care provider, our team delivers health care focused on quality care, provider performance and patient experience. This results in better coordination of care between specialists and hospitals and a patient-centered approach that includes your physical, mental and social needs.”

One element of the operational success of Complete Health’s physician practices has been the company’s partnership with Atlanta-based patient scheduling company Relatient. Why is patient scheduling such an important part of that? Relatient CEO Jeff Gartland recently told Healthcare Innovation, “Patient self-scheduling is incredibly important to providers. Consumers are demanding it, and yet it’s much more complex than anyone can imagine. In my view, since the pandemic, consumer need and demand for more convenient access is increasing exponentially. The patient experience is blurring between clinical outcomes and the consumer experience. You can be the best doctor, but a bad patient experience will impact you. The other half is that it’s incredibly difficult. People ask: Why can’t patients make appointments themselves, the way restaurant patrons make appointments through platforms like OpenTable? We use this analogy: Imagine if every time you wanted to book an appointment through OpenTable, you were given a massive amount of questions to answer. If you had to do that every time you book an OpenTable reservation, it would be the equivalent of what happens in healthcare. Leaders at Complete Health have used the Relatient platform as a tool to improve the patient experience.

Dr. Farley recently spoke with Innovations in healthcare Editor-in-Chief Mark Hagland discusses the transition from fee-for-service care to value-based healthcare delivery and payment and how this evolution has impacted him and his colleagues in his practice and at Complete Health. Below are excerpts from this interview.

How would you describe your practice and the larger organization?

We are a primary care medical group. 98 percent of the doctors in our clinic are general practitioners or internists. We also have a podiatrist and a sleep medicine specialist.

And the corporate entity that organizes your practice and the other Complete Health practices has private equity funding, correct?

Yes. The switch to value-based contracts for primary care is only possible through the takeover of the hospital or through capital injections. We have 41,000 patients in risk-based contracts.

Which accountable care and value-based programs do you participate in?

We’re about 60 percent commercial. We’re in a Medicare Advantage HMO; we’re in PPOs. And we have an ACO REACH contract that started when the program was called the Direct Contracting Program. ACO REACH is a great product for us. The majority of the patients we serve under risk-based contracts are in Medicare Advantage. And the great thing is that we treat all of our patients the same; they all get essentially a kind of concierge medicine.

The majority of our high-risk patients are in MA because we do everything the same; all patients essentially receive concierge medicine.

What percentage of your patients are cared for under risk-based contracts?

Of our 134,000 patients at Complete Health, over 37,000 are treated under full-risk plans—effectively 28 percent. When it comes to specialists, we carefully select which providers we include in our preferred network. Among other things, they must meet criteria for referrals from our providers, and we prefer them to use lower-cost locations for outpatient procedures—for example, ambulatory surgery centers rather than hospital outpatient departments—although patients ultimately have the choice of where they receive care.

Transitioning from performance-based payment models to value-based contracts is challenging and requires significant cultural change and change management. I note that your clinics operate in markets that would not be considered advanced managed care markets. Can you speak to the gradual change management processes required when working with physicians in less advanced markets?

I like to call us a disruptor. We talk to hospitals and specialists and ask them to do certain things. We buy practices and convert them into value-based practices over the course of a year or more. And some of the health plans have asked us to go into certain markets to help advance the physician practices in those markets. So being in those markets has proven to be both an advantage and a disadvantage. There’s a lot that you can sort out. Just putting together a network of preferred providers is a huge step. And changing the billing systems. And we go to specialists and set standards for how quickly patients should be treated.

How have you been able to change the doctor culture in these markets?

Because these are immature markets, we’ve actually been able to acquire some of the best performing practices. And we’ve been able to attract wonderful physician leaders. I’m 60; and there are a lot of physicians like me who don’t want to give up their practice but want to get off the rat race. So you get away from the mentality of fee-for-service, of squashing problems, and you take care of patients for life. So we change the reimbursement model within a year or two and shift the metrics from quantity to quality outcomes – STAR ratings, etc. And physicians typically make about 38 percent more in salary than they do in fee-for-service, based on the shared savings of not having patients go to the hospital or the emergency room. We pair care managers and social workers – in Birmingham alone, we have nine quality specialists plus member services staff – with the physicians. And then we use technology. We have a tool that shows gaps in care. It uses claims data. And we use athenahealth as our EMR.

We have set up a patient center and several outpatient clinics. And we check on our patients to avoid an emergency room visit. We engage patients heavily and do risk stratification using a Hopkins tool. And about 10 to 15 percent of those are the high-risk patients. And if you fall under that per capita agreement.

As you know, last month Medicare actuaries announced their spending forecastswhich predicts that current annual U.S. health spending of $4.6 trillion will rise to $7.7 trillion by 2032. That’s staggering. In your opinion, does this coming increase in costs inevitably force our health care system to move toward value-based payment?

Yes, that’s true. And my perspective is shaped by being a fourth-generation physician. My family started in medicine in 1896. My grandfather just played whack-a-mole with his patients’ problems. And over time, it’s become clear that we need to lower the cost curve; and the reality is that the value-based care model just makes sense overall. It’s clear that the longer we keep these patients, the better we get with them.

Tell me about your partnership with Relatient?

We implemented their solution in our patient access center just this spring. It’s a tool. You can book a hotel room or a plane ticket online. But in healthcare, you still have to call. Now Relatient is applying intelligence to scheduling; that’s phase one, we’ve implemented that and we can find appointments faster. The challenge was that we had to reorganize the doctors’ scheduling systems. But the average call time has gone down, our scheduling efficiency has improved significantly, and soon we’ll launch the patient self-scheduling feature tomorrow.

In addition, we get a lot fewer complaints from patients because we find appointments for them much faster. Patient representatives spend a lot less time with patients. We reduce the time per call from 8 minutes to 3-4 minutes. That will be a huge step forward. Younger patients use patient portals, but older patients want to call. But the ability for patients to make appointments themselves is great. We are very excited about the potential.

What key insights has your company gained so far on its path to value creation?

The hardest part was getting into those markets, getting the first contracts in place, and structuring them in a way that was beneficial to us. But the biggest challenge is changing the culture away from the fee-for-service mentality. And don’t send patients to the emergency room, treat them immediately. Access is more important because the earlier you treat the disease process, the better it is for everybody. You just have to make it palatable to providers because they hear “value-based care” and they think “cheap”; and I explain to them, no, in the fee-for-service system, you don’t have time to really care for patients and improve outcomes. Culture change is absolutely the hardest element of all of this.

Furthermore, data analysis is crucial for success, isn’t it?

Absolutely. We have six medical economists and an entire IT department. We’ve basically built our own data warehouse to create reports; we don’t have a formal population health management solution. As CMO, I live and die by those reports. I’m the one who pushes to make sure we have the data we need; you can’t be successful in VBC without the data. And a lot of organizations like Oak Street and ChenMed don’t care about all types of patients; we still care about all patients; that’s been helpful too.