The Pandemic Accelerates The Shift To Value-Based Advanced Primary Care Models

Over the last 11 months, the American healthcare system has been stretched to the breaking point.

In the past few months alone a new surge of COVID-19 cases has put new stressors not only on care teams but also on the financial models that underpin the entire system. Thought leaders like Dave Chase have even suggested that a major effort akin to the Marshall Plan will be required to save the American primary care system.

But, in the midst of these dire times, there are some who are looking ahead and asking how we might use the lessons and circumstances surrounding the pandemic to develop a new and better healthcare model.

Read Next: The In-Depth Guide to Value-Based Care: What It Is, Why it's Important, And The Best Way To Deliver It

In a recent conversation with Medical Economics, former CMS administrator and FDA commissioner Mark McClellan, M.D., Ph.D. shared his thoughts about how American healthcare can evolve as a result of COVID-19.

We were encouraged by his emphasis on the importance of using the current crisis to further accelerate the move into value-based models as well as his focus on the importance of primary care. Below we’ve summarized some of the takeaways, included some quotes from Dr. McClellan’s comments, and provided our take.

Accelerated pivots towards early care, especially in capitation models 

Dr. Mark McClellan’s comments:

“I’ve been particularly impressed with organizations that have already moved away from fee-for-service payments. Some of the organizations that are more advanced in capitated type models, those organizations didn’t have their revenue floor fall out from under them when utilization fell in March and April. They were already engaged in a lot of telehealth and longitudinal data management to monitor their higher risk patients. They had a relatively easy time adapting to what was needed in the pandemic, which was a shift towards early intervention with patients, managing risks, redesigning care to put an emphasis on sites of service that were more community- and home-based.”

Vera’s take

McClellan goes on to argue that this shift towards early intervention should be sustained beyond the pandemic in order to tackle other major health issues and better prepare for future public health crises. In our advanced primary care (APC) model,  we have seen this very approach drive improved outcomes. Member populations benefit when behavior change is emphasized in the primary care setting before significant cost and effort is required to provide the necessary treatment. You can read more about our approach to behavior change here.

Care delivery built around the needs of the patient

Dr. Mark McClellan’s comments:

“From a patient standpoint, people really have appreciated not just the ability to set up a telehealth visit, but all these services being reorganized around them and meeting their needs. Things like phone calls to let them know their risk. Or if they do have symptoms or a problem, connecting 24/7 to a nurse practitioner who knows their care and their records.”

Vera’s take

Telehealth, which we’ve written about here in detail, is just one element in a shift to providing the care that patients need in ways that work for them. This lines up with our APC model’s focus on aligning care delivery with the needs of specific populations.

Increased investment in primary care by payers

Dr. Mark McClellan’s comments:

“...they’re (Blue Cross of North Carolina) planning to move into so-called advanced medical home models over the next couple of years. This was a strategic direction that Blue Cross wanted to move in anyway, to get to better care. But it’s a special opportunity to do it now with some of the savings from reduced utilization that we’ve seen over the last few months, channeled directly into strengthening the practices and helping them move into these better models.”

Vera’s take

As you know if you read this blog, the core of our model involves providing a medical home where members can receive 80-90% of the care they need, as well as active care coordination when specialist care is needed.

Our APC model has proven that this approach improves outcomes while controlling the cost of care or even driving costs down for both payers and commercial clients. You can read more about our APC model here.

Half steps away from fee-for-service don’t work

Dr. Mark McClellan’s comments:

“I actually think that the challenge with MIPS is that it puts a lot of emphasis on some minor adjustments in fee-for-service. You still get paid on a fee-for-service basis. You still have to do all the billing, all the paperwork, and on top of that, you’ve got to make sure you’re reporting on all the measures and things like that. And some of the things that the metrics are intended to do, like avoid readmissions, or improve other aspects of quality, the fee-for- service system doesn’t really pay you that well to support.

So the kinds of reforms I think are more promising, and the ones that in recent CMS reports they’ve shown have led to more savings and bigger measurable improvements in care, are ones that do move a bit more away from fee-for-service. So for a primary care group, giving them a payment per person, as a medical home or direct contract payment, that they get up front, and that they can use to make new kinds of investments, restructuring their practice, moving towards more of a team-based approach to care, investing in new IT capabilities that they can use in collaboration with health plans and other community organizations to augment the scope of services they can provide to keep people healthy.

Vera’s take

The truth is simple. A broken healthcare system cannot be effectively fixed by making small changes to the existing model — a whole new financial model is needed. Our belief is that the answer is a value-based model.

You can learn how our APC model aligns with value-based care here.