How to Make APC Work for Everyone

APC is only possible if providers, payers, and employers agree to align around health outcomes rather than volume-based fee-for-service.

When APC is structured with incentives aligned to improve health instead of drive volume, care teams practicing in an APC model can measurably improve the health of their patient population while dramatically reducing the total cost of care.

The following capabilities are required:

Robust informatics

An informatics platform segments the population by risk, allowing the care team to target the highest risk, most impactable segments first. Customized outreach to members and speaking to their specific health situations encourages them to seek the care they need and boost adherence. Smart analysis of claims data yields actionable insight, opens opportunities to increase appropriate utilization, and enables care teams to close care gaps.

Integrated care coordination

Providers use high-value, low-cost specialty networks, allowing them to steer patients to the appropriate specialists when necessary. Care teams can not only schedule and manage specialty appointments, but most importantly, can schedule the necessary follow-up, and integrate specialty plans into the member’s overall care plan.

Professional health coaches

Clinically integrated health coaches are trained in the Transtheoretical Model (TTM) to help patients move through the five stages of change to improve their lifestyle and achieve life goals. Behavior change cannot be prescribed. Health coaches are essential stakeholders on the APC care team.

APC Is 1:1 Population Health

APC makes it possible to deliver 1:1 population health. And even on a 1:1 basis, population health is rooted in a firm understanding of the segments that make up a population and a strategy for providing the most appropriate care to each.

Every population can be broken down into three general segments:

Prevailing wisdom says it’s not possible to improve the health of the polychronic segment of a population, but providing these patients with the highest quality care at the most affordable cost is all that can be done.

Cases include cancer, premature births, and Alzheimers to name a few. Any improved outcomes and/or reductions in costs will need to come from the other two segments.

APC is designed to improve outcomes for the at-risk segment. Members in this segment live with underlying conditions that can benefit from proactive care and behavior change. APC enables care teams to take advantage of informatics to identify those at-risk members that can most benefit from care and make sure they receive the most appropriate care first.

Once engaged, at-risk patients benefit from the incredible care experience afforded by the APC model (read: true primary care with long, trust-building provider appointments) ensuring that they get the right type of care and health coaching to help them to make positive behavior changes that will improve their long-term health outcomes.

A different, but no less effective effort is aimed at understanding and appropriately treating the third segment, people who appear healthy but may have unseen, underlying health issues.

This segment of people who haven’t generated a healthcare claim is a huge blind spot for non-APC primary care practices without insights afforded by informatics. Treating this segment starts with preventive care, including screenings for common diseases found among members of the at-risk population, and continues with a more informed approach as this segment of the population engages.

The two most important goals for this segment are:

1. Help those who are truly healthy to stay healthy.
2. Identify people who only appear to be healthy because they have not yet been diagnosed with an underlying condition (i.e., generated an insurance claim). If they can be diagnosed and treated before they become at-risk, or even polychronic, APC will pay for itself.

APC Delivers Results

When implemented with the right partner, APC delivers three key results that justify redistributing benefit funds to focus on primary care:

Improved health outcomes

By leveraging informatics and claims data to tailor care to address the care gaps and specific needs of a population, health outcomes are improved over time. The model’s strong emphasis on preventive care, the increased access it provides to members, and its focus on behavior change mean that these outcomes can be sustained over time.

Reduced total cost of care

APC requires an upfront, increased financial allocation toward primary care. The investment drives more utilization through primary care, which in turn reduces utilization of uncontained downstream care across all other portions of the healthcare system. The result is a dramatic return on investment through a reduction in total cost of care — reduced specialist care visits, decreases in hospital and ED utilization, and even lower drug costs.

Higher patient satisfaction

There’s no more powerful experience for a patient than to know and trust their primary care team. The wraparound experience — where a patient feels heard, known, and empowered — meets them where they are at and increases satisfaction exponentially. In fact, members benefitting from Vera’s APC model consistently yields satisfaction scores above 4.6 out of 5.

Validated outcomes

In addition to the results shared above, the Vera Whole Health APC model was the first to earn a Certificate of Validation from the Validation Institute and is the only primary care model to earn two validations — for population cost and health outcomes.

Dr. Kevin Wang

Chief Medical Officer, Vera Whole Health
Advanced Primary Care

At Vera, we’re not only bringing in more advanced care practitioners like (MDs or NPs) and using a care team to coordinate care like many others are in the industry, but with APC we’re also adding behavioral change management, health coaching, and data analytics to drive it.

Our model isn’t about doing more with less. We’re about doing a lot more with the right team so that there are fewer gaps in care for the patient.

This stands in stark contrast to the typical focus on increasing productivity. For example, physicians who were able to serve a patient panel of 2,000 with one medical assistant were challenged to come up with ways to serve 4,000 without adding an additional provider. This wasn’t really possible without a significant drop in the quality of care. This is why our APC model is so revolutionary. Rather than focusing on productivity, it achieves increased quality and health outcomes at a lower cost by providing whole person care in an environment that emphasizes outcomes over efficiency.

Benefits to Patients

In APC’s value-based model, patients receive the care they need to be healthy (and not just the care needed for providers to meet fee-for-service quotas).

Patients benefit from three differentiators:

1. Whole person care

Providers move beyond symptom management because they have the time to explore the underlying issues beneath those symptoms — which aren’t limited to physical issues but includes all the social determinants that affect health. Once these are uncovered over time, a plan can be developed to address them.

2. Significant cost reduction

When APC is backed by an employer or provided by a payer as part of a health plan, care is delivered at little or no cost to the patient. That’s a huge benefit, especially today when many patients ignore their health because they can’t afford treatment or defer care due to high co-pays or deductibles.

3. Individualized, efficient support

The APC model also helps patients experience the best of both worlds: the resources they need for a healthy lifestyle and healthcare that doesn’t bleed them dry.

When APC is backed by an employer or provided by a payer as part of a health plan, care is delivered at little or no cost to the patient.

Benefits to Employers

Self-insured employers get four key benefits from APC:

1. Reduced healthcare costs

Employers often face a cycle of increasing cost curves for years, forcing them to choose between reducing benefits or cost-shifting to their workforce to stay solvent. When self-insurers pair with APC, they gain more control over their benefit and plan design, reclaim consistency over a key part of their balance sheet, and retain lower overall costs of care.

2. Reduced absenteeism and increased productivity

APC empowers and educates employees to take greater ownership of their health goals with the support of a primary-care focused model focused on preventive health and wellness. APC’s proven results lead to healthier employees — and healthy employees are happier, more present, and more engaged in their workplace.

3. Improved health outcomes for workforces

Employers that decide to implement APC with a proven partner can dramatically enrich the healthcare benefits they provide while also flattening the curve of their benefit costs. This case study explains how.

4. Improved talent acquisition for employers

Today’s workforce (the largest percentage of which are Millennials) is looking for better healthcare options that are simple and focused on their holistic health. APC allows employers to provide just that and, as a result, gain a competitive recruiting advantage.

When self-insurers pair with APC, they gain more control over their benefit and plan design, reclaim consistency over a key part of their balance sheet, and retain lower overall costs of care.

Benefits to Payers

Payers looking to build a competitive advantage in their markets will set themselves apart from their competition in five specific ways when they implement APC:

1. Control of the supply chain

Primary care gives payers the ability to provide most of the care that most members need through primary care centers. With analytics, care coordination, virtual care, and health coaching baked into the APC model, payers can improve outcomes across large populations and drive down total cost of care.

2. Increased member access

Payers can address the primary care shortage within their regions by embedding dedicated primary care access for members into health plans. With little to no cost to members and primary care teams who can focus on these populations, payers remove access barriers (physical, financial, and even cultural) that would otherwise depress primary care utilization and frustrate their members.

3. Improved quality

For payers who serve Medicare Advantage members, APC enables improvement of HEDIS and star measures. In addition to CMS bonuses, payers also see financial returns from improved risk adjustment (RAF increases) and total cost of care reductions.

4. Excellent member experience

APC enables longer appointment times. This allows members more time and space with their care teams to get at the root of their health issues. The result is that members feel heard — sometimes for the first time in their lives.

5. Market differentiation

Payers signal value with APC and create the right alignment with their partners and across the system. Getting into care delivery with APC changes the conversation from renewals, authorizations, and networks to health, well-being, and communities.

With analytics, care coordination, virtual care, and health coaching baked into the APC model, payers can improve outcomes across large populations and drive down total cost of care.

Benefits to Providers

APC isn’t just a model that works for those who are receiving care or paying for it. It is also a model in which those who deliver care thrive. There are three main reasons for this:

1. Providers can focus on quality, not production

In the APC model, financial incentives are based on the quality of care provided, not reimbursement for procedures. This means there isn’t a reason to rush through as many patients as possible over the course of the day. As a result, a provider typically sees half as many patients in a single day and spends more time with each.

2. Providers operate at the top of their license

Because APC focuses on providing 80-90% of care in the primary care setting, providers are encouraged to do more than just serve as a gatekeeper to specialty care. They become the key medical provider to their patients and are able to use the full scope of their training and skills to help improve the outcomes of their patients.

3. Care teams provide the support to make whole health care possible

In addition to having more time with patients and the incentive to provide whole health care to their patients, they also have the necessary support. At Vera, care teams are structured so that there are not only nurses and allied staff supporting the provider but also whole health coaches, who are experts in behavior change, and behavioral health professionals who can help support patients with behavioral or mental health concerns.

In the APC model, financial incentives are based on the quality of care provided, not reimbursement for procedures. As a result, a provider typically sees half as many patients in a single day and spends more with each.

What Inspired APC?

Here are the healthcare models and approaches that influenced and shaped what APC is today:

Managed care

Managed care has been used as a framework for benefits plans for decades. It promises to centralize patient care within a single network or provider system aimed at containing costs and improving patient health outcomes.

In concept, managed care makes sense. In practice, it didn’t work. It ended up simply controlling access to care in order to reduce costs rather than also focusing on outcomes.

In a traditional managed care environment, patients are incentivized to use in-network providers and specialists, regardless of provider cost or quality. And they’re punished financially for getting care outside their network, whether it’s a wide PPO or narrow HMO. But constraining patients to a network, no matter how large or small, doesn’t necessarily mean they get better health outcomes. Especially if the network is based on the reactive sick-care system where symptom control and disease management are nothing more than Band-Aids on underlying health problems.

Accountable care organization (ACO)

ACOs were designed to hold groups of providers across different care settings accountable for the cost and quality of care provided to a defined group of specified members.

The whole point was to give providers an incentive to work together and better manage patient care. This is good; it placed an emphasis on effective primary care and its role in coordinating and managing care to drive down unnecessary costs.

But there’s a significant dilemma: what about everyone else? And more than that, for patients who were part of an ACO, which might only be a few on any given week, it was impossible for care teams to suddenly shift course midstream to provide higher quality care at a lower cost.

Most care teams wouldn’t know if a patient was part of an ACO to begin with. And even if they did, they didn’t have the time or resources to do anything more for these patients than everyone else.

Medical home

Establishing a “medical home” is the first step towards advanced primary care. Broadening the scope and centralizing the role of primary care (and primary care teams), a medical home improves population health, lowers costs, and provides a better, values-based experience for patients.

This is a model where primary care is the central hub in the patient’s care journey. Where access is nearly unlimited for patients.

But where a medical home falls short is in its failure to use data to drive health outcomes across a specific population. And that means a limited ability to address the specific risks of the population.

At Vera, we analyze over two years of claims data to develop a clearly defined understanding of the risks for each population we serve and the opportunities to improve health outcomes, all the way down to the individual member.

This specificity also helps create the right message to patients so we can better promote the clinic and communicate why it’s important to them.

APC’s Core Capabilities

Each of the following four capabilities play a crucial role in the model’s ability to deliver improved health outcomes at a lower cost. Let’s take a deeper look:

Robust informatics

The APC model leverages an informatics platform that analyzes numerous data sets, including insurance claims and electronic medical record (EMR) data, to ensure optimal care is provided to the population that the APC model is serving.

How robust informatics contribute to the model’s effectiveness

Although informatics improves the overall performance of the entire model, there are three essential ways that it contributes to effectively improving the health outcomes for an entire population:

1. It identifies segments of the population that could most benefit from increased or different care due to the underlying health issues they’re living with. These segments can then be targeted for increased engagement and different levels of care to improve their long-term outcomes.
2. It allows care teams to identify who is most in need of screenings and other preventive measures, both to identify those who are apparently healthy, and actually need higher levels of care, and to encourage continued healthy choices for those who do not need increased care.
3. It can identify care gaps that may not be immediately evident so that they can be addressed before they impact the overall health of the population.

Active care coordination

In a typical primary care setting, providers serve as referral machines to specialty care. Instead of having time to spend diagnosing the cause of a patient’s symptoms, they have to quickly refer the patient out for costly procedures and specialty care — that may or may not solve a patient’s actual underlying health issues and with little linkage back to their primary care provider.

In the APC model, primary care providers serve as the quarterback of a patient’s care. They and their care teams spend the time in the primary care setting to provide all the care possible. Then, if more care is needed than can be provided at the care center, patients are sent to high-value specialists. Once their specialty care is complete, follow-up is handled in the care center. All of this care is tied together nicely by a care plan.

How active care coordination contributes to the model’s effectiveness

Active care coordination may seem like a simple concept, but it isn’t common. When implemented correctly within the APC model, it has three specific positive impacts:

1. Patient outcomes from specialty care increase because the primary care team has spent adequate time with the patient ahead of time to ensure the right specialty care referral is made for the patient’s diagnosis.
2. The patient experience improves because a patient is no longer left to fend for themselves in a complicated healthcare system. Primary care teams guide them through each step of the way, reducing stress and wasting less time.
3. The long-term health outcomes of patients improve because the primary care team is involved in all follow-up, better ensuring ongoing adherence to whatever treatment plan the specialty care provider recommended.
4. Specialists are empowered to practice at the top of their licenses because they only receive fully screened referrals.

Clinically integrated behavior change coaches

In the APC model, clinically integrated behavior change coaches operate as a key part of the care team. Their role is to walk alongside patients using TTM to help patients change their behavior to improve their lifestyle and achieve life goals. These coaches team up with providers and behavioral health professionals to provide whole health care to patients.

How clinically integrated behavior change coaches contribute to the model’s effectiveness

Clinically integrated behavior change coaches certified in TTM have a significant impact on the APC model in three specific ways:

1. Coaches help patients to see their health from a different perspective, one from which they have control and can make positive decisions to live healthier lives.
2. They improve adherence to the advice that patients receive from their providers by immediately being able to work with the patient on a plan and health goals.
3. They serve as a key partner for patients seeking to make positive changes in their behavior by being available to provide support and empowerment in the patient’s journey.

Empathetic listening

The final capability required to effectively implement the APC model is empathetic listening. Empathetic listening builds on active listening so patients feel truly heard and understood. When physicians, nurses, and health coaches are trained in and employ empathetic listening, they help their patients achieve positive health outcomes.

How empathetic listening contributes to the model’s effectiveness

In many ways, empathetic listening is the core to the success of the APC model. But there are three specific ways that it disproportionately impacts the model’s effectiveness.

1. Empathetic listening moves the focus of the healthcare experience squarely onto the patient. Too often, patients feel that they are just another cog in the healthcare machine. Not so when empathetic listening is employed.
2. One of the practical results of empathetic listening is esteem, how we describe when a patient feels heard, understood, and empowered. When patients feel esteemed by their provider and care team, they begin to believe in themselves and their eyes are opened to their ability to make a positive impact in their own health.
3. Empathetic listening allows providers and their care teams to get below the surface and identify the true health needs of patients, and it allows them to actively partner with their patients to meet those needs.

The Key Consideration for Payers: Build or Buy

The biggest question payers face when they decide to get into the business of primary care delivery is whether they will build the care delivery system from scratch or buy it by working with an experienced partner.

Building and buying both come with their own challenges.

The right approach will depend on the capabilities of the payer and the speed at which they want to launch a primary care solution to their members.

As you evaluate which approach to pursue, we recommend asking these four questions:

1. Do we have the infrastructure needed to build and operate a primary care system?
2. Do we have the budget to develop a care delivery system?
3. What level of control do we need? And can we achieve that with a partner?
4. If a partner could effectively serve the needs of our population, would we still build?

Your answers to these questions will help you determine the path of least resistance for your efforts to get an APC model up and running. You can learn more about how to think about these questions here.

The Key Consideration for Employers: Flipping the Paradigm on Benefit Strategy Design

Self-insured employers face a different challenge than payers. The biggest thing they need to do is flip the paradigm of how they approach benefit strategy design.

Employers are accustomed to the two realities of benefit strategy design within a fee-for-service healthcare system. Costs always go up and, as a result the benefits that you can provide always go down.

Employers are consistently evaluating how to reduce healthcare costs without completely hurting the ability of their workforce to get the healthcare they need. This constant juggle often leads to cost-shifting towards patients in the form of high-deductible health plans. The only problem is, these plans further exacerbate the key problem with the fee-for-service healthcare model. Patients who have to pay more for care will only go to the doctor when they get really sick.

APC offers a different option that encourages patients to seek out care early and often. And while it may seem counter-intuitive that increased utilization reduces cost, we’ve proven that this value-based model will drive significant cost savings through reduced claims. In fact, we guarantee this to happen when we work with an employer. You can learn more about how we did this with the City of Kirkland here.

There’s no reason to expect that you must spend 15% more than you did last year on your benefit strategy. You just need to approach the problem differently.

Get in Touch with Vera Whole Health to Learn More About Advanced Primary Care

The future of healthcare is being built now and advanced primary care is paving the way. Don’t get left behind. Instead, join us. If you’d like to find out more about advanced primary care and what it could do for you and your organization, let’s talk.

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