Can Providers Scale Value-Based Care Sustainably?

In the healthcare world, everyone wants to achieve better outcomes at lower costs. But this is much easier said than done, pointed out Dr. Patrick Runnels, chief medical officer at Cleveland-based University Hospitals.

“We’ve been pursuing better outcomes at a lower cost without changing the fee-for-service expectations, which means we’re adding a bunch of stuff on top of the stuff we’re already asking physicians to do — that’s what value-based care has been so far,” he declared in an interview at a recent conference.

In other words, the way value-based care is currently practiced at health systems results in hours of new administrative tasks for physicians, including increased responsibilities for documentation, care coordination, patient engagement, preventive care outreach, and the tracking of financial and population health metrics. Without addressing this problem, value-based care models will never be able to reach true scale, Dr. Runnels said. 

But the adoption of new technology, coupled with workflow training from fellow physicians, can help address this issue, according to population health experts.

The value-burden ratio

Dr. Runnels noted that University Hospitals saved $50 million across its accountable care organizations (ACOs) last year.

“We’re really happy with that — but it’s at the cost of our primary care providers feeling like they’re drowning. We have high value, but the burden to get that value is also very high,” he remarked. “That value-burden ratio is the key to actually making value-based care sustainable.”

The burden that Dr. Runnels refers to can mean a number of things. Switching to a value-based approach often means that physicians have to spend more time delivering higher-quality care, be more thorough with their documentation, and increase their number of clicks before completing a task. The burden could also encapsulate the negative emotions physicians have when faced with a sudden change to achieve a result that feels unattainable, as well as a perceived forfeiting of autonomy, Dr. Runnels explained.

For example, a primary care physician with 300 hypertensive patients might be asked to make sure that at least 80% of these patients have blood pressure readings below 140/90 mm Hg. They might also be asked to make sure all patients attend a follow-up visit within a week after being discharged from the hospital, he said.

Adopting value-based care models comes with a “very serious” added administrative burden, agreed Anna Basevich, senior vice president of enterprise partnerships and customer enablement at Arcadia, a health data platform.

“We’ve taken a lot of responsibilities that health plans used to own, and we more or less shoved them onto provider systems,” she said.

Many of today’s doctors spent the first couple decades of their career operating on fee-for service models, Basevich explained. This means that they were really only responsible for the visits they had scheduled that day. A patient would come into the clinic with their problem — whether it was a broken arm, trouble sleeping or a diabetes flare-up — and treat them to the best of their ability for the duration of the appointment. 

After being migrated to a value-based care model, physicians quickly become responsible for a lot more than these episodic care needs.

“Once somebody’s crossed your doorstep a couple times, you’re then responsible for the full scope of their disease burden and outcomes. You’re responsible for whether or not someone’s talking to them about smoking cessation. You’re responsible for getting their cancer screenings — you can put in an order for that, but then what can you do? Call the person eight times to find out whether or not they’ve actually gotten the screening? There’s a lot of burden that’s shifted there,” Basevich remarked. 

This is the reason that you don’t see many individual providers entering value-based contracts, she noted. There is just too much burden that would fall solely on the individual.

Listening to all physicians’ voices

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

Even if that estimate isn’t perfect, the administrative burden that comes along with value-based care is often demoralizing to physicians — as well as somewhat dehumanizing, given physicians are expected to meet impossible standards, Dr. Runnels said.

Physicians are burnt out as it is, without adding a bevy of new tasks aimed at improving referral management, financial tracking, health outcomes and preventive care, he pointed out. For instance, a physician might be tasked with ensuring 90% of their patients have received vaccinations or cancer screenings, which can feel incredibly daunting when you see hundreds of patients per month, he added.

Finding ways to eliminate physicians’ administrative burden will allow them to restore joy in their work and return to the reason most of them got into the field: to help patients. This will likely create a virtuous feedback loop of performance — in other words, it’s easier to provide exceptional care experiences when you’re not bogged down by hours of stressful tasks, Dr. Runnels noted.

In an effort to reduce its physicians’ administrative burden, University Hospitals has recently assembled a rotating work group to learn more about its physicians’ daily experiences and pain points.

“There’s 12 physicians from 12 different types of practices — some rural, some urban, some Medicaid-heavy, some commercial-heavy. They ask, ‘What are your pain points? What’s going on?’ and the story is very different from doctor to doctor,” Dr. Runnels said.

For instance, one physician may be struggling with documentation, and another may be far more concerned with making their scheduling processes more efficient than they are worried about documentation, he explained. Or one physician could be in desperate need of more team members, and another could stand to reduce the size of their team, he added.

As it continues its problem identification work, University Hospitals’ working group will likely start to notice pain points that can be addressed through AI tools, Dr. Runnels pointed out.

As this happens, the plan is for the working group to conduct micro-pilots, he said. That means that two or three doctors will try out a technology for a day or so and then report back to the group to talk about what worked, what didn’t and what could be tweaked.

Having this apparatus to quickly test new tools in a physician’s working environment allows innovation to happen faster, Dr. Runnels remarked.

“A lot of health systems just say, ‘Here, we’re giving you technology.’ But that’s not helping anything if you aren’t grounding it in the fact that the technology’s job is to reduce burden, and that’s why this stuff is there. If we’re not scientifically identifying problems and getting the group together to do that, then we’re going to miss the boat. Technology is going to be implemented very haphazardly, and it’s going to be low-value,” he declared.

Technology is never the end-all and be-all solution

In order to succeed in value-based care, physicians need two things, according to Basevich of Arcadia: to be attached to a greater community via a hospital affiliation, and the right technology to track the seemingly never-ending slew of value-based care variables and metrics.

In Basevich’s view, the two main competencies are clinical documentation and care management. Providers need technology to make sure their patients’ conditions are being captured accurately so their care journey can be managed and their data can be submitted to their health plan. Additionally, providers need tools to help them make sure patients receive the appropriate preventive care and disease management services, she explained.

There are dozens of vendors — like 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 enabler that helps providers make sense of their data and better manage their patients’ health, but it has to be implemented thoughtfully, pointed out Courtney Fortner, CEO of population health company Navvis.

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

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

Sometimes, health systems assume physicians will do a good job of HCC coding after a simple training session. But this approach is likely to annoy physicians, making them feel burdened with yet another EHR task, Fortner explained.

“We don’t really talk about training on HCC coding. But we do talk about early disease recognition. We have practicing physicians talking to other practicing physicians about how to extend the life of their patients. And when they do that, a derivative positive implication is talking about accurate HCC coding, but the physicians absorb it much differently,” she said.

In Fortner’s view, University Hospitals’ made a wise decision to leverage its own physicians in its administrative burden reduction work group.  

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

Technology will undoubtedly be an important part of alleviating the administrative burden that comes along with physicians entering value-based care contracts — but one should never underestimate the power of human connection nor the fact that physicians need to be trained by someone who has been in their shoes before, Fortner said.

Taking the time to carefully implement the right tools and change management processes is vital when moving physicians to value-based care models. These considerations can help ease the administrative burden that comes along with these contracts. That, in turn, could help health systems scale their value-based care initiatives more sustainably in the future.

Photo: marchmeena29, Getty Images