Can providers sustainably scale value-based care?

In healthcare, everyone wants to achieve better outcomes at lower costs. But that’s easier said than done, says Dr. Patrick Runnels, chief medical officer at University Hospitals in Cleveland.

“We’re looking to deliver better outcomes at a lower cost without changing expectations about how we’re going to be reimbursed for services. That means we’re adding a lot to the things we’re already asking physicians to do — that’s what value-based care has been,” he said in an interview at a recent conference.

In other words, The way value-based care is currently practiced in health systems creates hours of new administrative tasks for physicians, including increased responsibility for documentation, care coordination, patient engagement, preventive care education, and tracking financial and population health metrics. Without addressing this issue, value-based care models will never be able to achieve true scale, Dr. Runnels said.

But public health experts say the introduction of new technologies combined with workflow training from other physicians can help solve this problem.

The value-burden ratio

Dr. Runnels noted that university hospitals saved $50 million in their Accountable Care Organizations (ACOs) last year.

“We’re really happy with that – but that comes at the expense of our primary care providers, who feel like they’re drowning. We have a high value, but the burden to achieve that value is also very high,” he noted. “That value-burden ratio is the key to making value-based care truly sustainable.”

The burden Dr. Runnels refers to can mean several things. Shifting to a value-based approach often means physicians must spend more time providing higher quality care, be more thorough with documentation, and make more clicks before they can complete a task. The burden could also include the negative feelings physicians have when faced with a sudden change to achieve an outcome that seems unattainable, as well as a perceived loss of their autonomy, Dr. Runnels explained.

For example, a GP with 300 hypertensive patients might be asked to ensure that at least 80% of those patients have a blood pressure below 140/90 mmHg. He might also be asked to ensure that all patients attend a follow-up examination within a week of being discharged from hospital, he said.

The introduction of value-based care models brings with it a “very serious” additional administrative burden, agreed Anna Basevich, senior vice president of corporate partnerships and customer service at Arcadia, a healthcare data platform.

“We have taken over many responsibilities that previously lay with the health insurance companies and more or less passed them on to the service providers’ systems,” she said.

Many of today’s doctors worked on a fee-for-service basis for the first decades of their careers, Basevich explained. That meant they were only really responsible for the visits they had scheduled that day. A patient would come to the clinic with a problem – be it a broken arm, trouble sleeping or a diabetes flare-up – and would receive the best care possible throughout the appointment.

After moving to a value-based care model, physicians quickly assume far more responsibility than just these episodic care needs.

“If someone has come to you a few times, you are responsible for the entire burden of disease and the consequences. You are responsible for whether or not someone talks to them about quitting smoking. You are responsible for making sure they get cancer screenings – you can issue an order for that, but what can you do then? Call the person eight times to find out whether or not they actually got the screening? That is a lot of the burden being shifted onto others,” Basevich noted.

This is the reason why not many individual providers enter into value-based contracts, she noted. The burden falls solely on the individual.

Hear the voice of all doctors

Dr. Runnels cited a recent study showing that a primary care physician would have to work 27 hours in a 24-hour day to effectively manage all value-based care metrics and close all gaps in care.

While that estimate may not be entirely accurate, the administrative burden that comes with value-based healthcare is often demoralizing for physicians — and somewhat dehumanizing, given that they are expected to meet impossible standards, says Dr. Runnels.

Doctors are already burned out without adding a host of new tasks to improve referral management, financial monitoring, health outcomes and preventive care, he stressed. For example, a doctor might be tasked with making sure 90% of their patients have been vaccinated or screened for cancer, which can be incredibly daunting when you’re caring for hundreds of patients a month, he added.

If doctors can find ways to reduce their administrative burden, they can regain their joy in work and return to the reason they got into the profession in the first place: helping patients. This will likely create a positive performance feedback loop — in other words, it’s easier to provide exceptional care experiences when you’re not busy spending hours on stressful tasks, Dr. Runnels noted.

To reduce the administrative burden on its physicians, University Hospitals recently formed a rotating working group to learn more about its physicians’ daily experiences and problem areas.

“There are 12 doctors from 12 different practices — some rural, some urban, some Medicaid-focused, some commercial-focused. They ask, ‘What are your pain points? What’s going on?’ and the story varies greatly from doctor to doctor,” Dr. Runnels said.

For example, one doctor may be struggling with documentation, while another may be more interested in making their scheduling more efficient than worrying about documentation, he explained. Or one doctor may desperately need more team members, while another may be able to reduce the size of their team, he added.

As the University Hospitals team continues to identify problems, it is likely that they will identify weaknesses that can be addressed using AI tools, Dr. Runnels said.

The plan is for the working group to conduct micro-pilots, he said. This means that two or three doctors will try out a technology for about a day and then report back to the group on what worked, what didn’t and what could be optimized.

Having these devices available to quickly test new instruments in a physician’s work environment can speed up innovation, Dr. Runnels noted.

“Many health systems simply say, ‘Here, we’ll give you technology.’ But that doesn’t help unless you understand the fact that the job of technology is to reduce the burden, and that’s what these things are for. If we don’t identify the problems scientifically and get the group together to do it, we’re going to miss the boat. The technology will be implemented very haphazardly and will have little value,” he explained.

Technology is never the ultimate solution

For value-based care to be successful, Arcadia’s Basevich says, physicians need two things: They need to be connected to a larger community through a hospital affiliation, and they need to have the right technology to track the seemingly endless barrage of variables and metrics of value-based care.

From Basevich’s perspective, the two key skills are clinical documentation and care management. Providers need technology to ensure their patients’ conditions are accurately recorded so their treatment history can be managed and their data can be transmitted to their health insurance company. In addition, providers need tools to help them ensure patients receive appropriate preventive care and disease management services, she explained.

There are dozens of vendors – such as Epic, Cerner, Signify Health and Premier, to name a few – that can help providers with the core competencies of value-based care, she noted.

Technology can be a fantastic tool to help providers make sense of their data and better manage their patients’ health, but it must be used wisely, says Courtney Fortner, CEO of population health company Navvis.

“I think a lot of systems just focus on technology and payment models. They say, ‘Okay, this is going to change the physician experience and this is how we’re going to deliver value-based care.’ But I really emphasize changing your processes and aligning your leadership to provide the right support to physicians as an extension of themselves,” Fortner explained.

To illustrate her point, she used the example of hierarchical disease category (HCC) coding. HCC coding refers to a risk adjustment model used by Medicare and other payers to estimate patients’ future healthcare costs.

Sometimes health systems assume that physicians will do a good job of HCC coding after simple training, but that approach is likely to frustrate physicians and make them feel burdened with yet another EHR task, Fortner explained.

“We don’t really talk about training on HCC coding. But we talk about early detection of disease. We have practicing physicians talking to other practicing physicians about how to prolong the lives of their patients. And when they do that, a derived positive consequence of that is that they talk about accurate HCC coding, but the physicians take it very differently,” she said.

According to Fortner, the university hospitals’ decision to use their own doctors in their working group to reduce administrative burden was a wise decision.

She said she recently spoke with a physician who told her that his “eyes glaze over” when non-clinicians try to educate him on new workflows and what they mean. The same person noted that the experience feels very different when another physician walks them through something like new reporting requirements and explains why they’re important.

Technology will undoubtedly play an important role in reducing the administrative burden that comes with doctors entering into value-based care contracts, but don’t underestimate the power of human connection or the fact that doctors need to be trained by someone who has been in their situation, Fortner says.

As physicians transition to value-based care models, it is important to take the time to carefully implement the right tools and change management processes. These considerations can help reduce the administrative burden that comes with these contracts. This, in turn, could help health systems scale their value-based care initiatives more sustainably in the future.

Photo: marchmeena29, Getty Images