As healthcare sprints toward value and away from volume, many physicians participating in value-based care (VBC) models are in the middle of a precarious balancing act right now. Value-based contracts demand different business and clinical practices from fee-for-service arrangements based largely on volume of service. And because many physicians still rely primarily on fee-for-service arrangements for the bulk of their livelihoods, practices often can’t afford a complete pivot toward value-based care.
This position is often illustrated with the idea of these providers having one foot in two canoes – one in a fee-for-service boat and the other in a value-based care boat – that are drifting apart.
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As providers look to find more stability as they pivot into VBC waters, they need to be conscious of the partnerships they forge on this journey. Done correctly, the right collaborative approach can have significant positive downstream impacts for all of a practice’s patients – even the ones not currently in a VBC plan.
Successfully navigating the VBC landscape requires adopting new operational processes, workflows, and more. To enable this conversion, two leading methods have emerged. The first delivers interventions but is less collaborative and inclusive than the second option, which transparently partners with physicians.
The first design operates as more of a “behind-the-curtain” approach, in which a VBC organization delivers support and resources to a patient in the program, often independent of the direct care being delivered by that patient’s physician. This type of value-based approach, however, limits providers’ visibility into the entire process—their ability to connect the value-based dots and information sharing between the patient’s physician and other members of the larger VBC team. This results in physicians not being able to learn and appreciate the many advantages of a value-based model, and they can remain uninvested in the changes needed at the physician practice to truly move the needle in patient care. It relegates the provider to being a doer in only one aspect of that individual patient’s care, and lacks alignment with other aspects of more holistic care delivery that can truly make a difference in a patient’s overall health and wellbeing.
This limited-participation design has a number of notable short- and long-term drawbacks. For the providers, it leads immediately to missed opportunities for improved clinical outcomes and shared savings, as well as friction between VBC and non-VBC providers.
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This lack of engagement inevitably slows their realization of moving more fully into value-based care and the potential patient care and financial benefits of other models that include downside risk and capitation.
For the patient, it can negatively affect their relationship with the practice. Having another set of healthcare professionals to interact with becomes confusing and less convenient–and can ultimately cause them to disengage.
Partial provider engagement also can result in a situation where only those patients covered by a VBC contract see the benefits of it, creating unequal tiers of healthcare, even within one provider’s office. This inequity is the exact opposite of what value-based care is designed to help accomplish. Pairing the provider flexibility with VBC models’ financial incentives should improve care quality and value to the point of making health equity an achievable reality.
The second, full-engagement, model concentrates on completely integrating providers with their VBC-enabling partners so they become a true extension of the phycisian’s own team and equal partners in the value-based care collaboration. This transparent, high-touch approach not only facilitates better care and service, it allows physicians to see the direct impact VBC has on their patients and their bottom line.
Because these physicians have a front row seat to the benefits of VBC and get to take more ownership of it, they are more likely to extend the full benefits delivered by this type of care to every patient regardless of whether they are covered by a VBC agreement. This halo VBC effect has a large, demonstrable impact on patients – in safety, outcomes, satisfaction, and health equity. All patients in an engaged VBC practice get more time with their physician or extended care team, and feel more seen and more cared for. They have access to the education and support that allows them to take more ownership of their health journey. No “haves” and “have nots,” only providers and patients sharing equally in the proven advantages of a holistic VBC practice.
The benefits of this second approach can be seen clearly in the nephrology space. In the nephrology practices we work with, the VBC infrastructure is designed to augment and amplify what practices are already trying to do, adapting to the practice’s workflows. New VBC resources such as embedded care coordinators, additional advanced practitioners, wrap-around transition management services, and patient education materials, are all integrated with physician input and buy-in.
One example of this fully-engaged VBC model comes from a rural nephrology practice in North Carolina that partners with a VBC kidney care management company for support. In rural areas, nephrologists frequently find themselves serving as the only physician who their patients see. To address behavioral health challenges in the area, this practice built out depression screening resources, with the help of their VBC support partners, to help them get comfortable with diagnosing and treating mild depression. This holistic value-based move helped head off many of the substantial effects that behavioral health challenges can have on physical health, well-being, and quality of life.
Another nephrology practice, also in in North Carolina, is an illustration of the benefits of physician involvement in a VBC model. They have successfully used embedded care coordinators to manage patients’ transition more successfully from late-stage to end-stage kidney disease. Disease progression can be trying for patients. Their disease is complex, resources are limited, patients often are seeing multiple providers, and they don’t feel well, which can affect their adherence. It’s very difficult for the nephrologist, alone, to manage these patients and their many needs. But by intentionally partnering with the care coordinators, and sharing information constantly, the physician is able to guide these patients to a better overall quality of life.
Kidney patients benefit when their physicians are fully bought in and engaged with value-based care. They experience slower disease progression, fewer hospitalizations, remarkable improvements in planned transitions to dialysis, and reduced overall costs of care. Additionally, these patients express more satisfaction with their care team, the education provided, and the resources available to them.
The entire healthcare industry must develop value-based care models which deliver superior clinical outcomes while lowering costs. This is the essence of value-based care. We believe that strategies which closely align with physician practices offer the best chance of achieving sustainable, safe, long-term quality and equity for patients.
George Hart, MD, is the chief medical officer for Interwell Health, a value-based kidney care management company that partners with physicians to reimagine healthcare. He brings three decades of experience in nephrology and as a practicing physician to his role and has worked extensively with physician practices in their transition to value-based care.
Jessica Demaline, MSW, LSW, is senior vice president, Healthcare Operations, for Interwell Health, a value-based kidney care management company that partners with physicians to reimagine healthcare. She has an extensive background in social work and behavioral health and has built a successful record of leading value-based care programs and population health management initiatives.
