The Future of Value-Based Care and the Emerging
Description: The Future of Value-Based Care and the Emerging Importance of Health Equity Presented by Frank Exposito, American Choice Healthcare Jonathan A. Fialkow MD, FACC, FAHA, Baptist Health Peter Young, Healthcare Strategic Issues Mike Segal,
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slide1. The Future of Value-Based Care and the Emerging Importance of Health Equity Presented by
Frank Exposito, American Choice Healthcare Jonathan A. Fialkow MD, FACC, FAHA, Baptist Health Peter Young, Healthcare Strategic Issues Mike Segal, Nelson Mullins Moderator: Ed White, Nelson Mullins
November 3, 2022<br>
slide2. What Is Value-Based Care? Value-based care is a healthcare payment system that ties payments to the quality of care provided, and rewards providers for both efficiency and effectiveness. It has emerged as a clear alternative to the fee-for-service payment system. Value-based payment systems are designed to provide higher quality healthcare services for patients while lowering cost. This shift in payment methodologies is sometimes referred to as reimbursement reform.
The evolution from fee for service to value-based care is proving to be a long and tedious journey, but it continues to move forward. 2<br>
slide3. Three Reasons Why Providers Should Be Focusing On Value-based Care IT’S INEVITABLE
The cost of healthcare as a percentage of the U.S. gross national product has risen steadily for the past 20 years, and as of 2020 was 19.7% of GNP. This is unsustainable.
In 2020 there were 54 million Medicare beneficiaries; by 2030 there will be 80 million. CMS has announced that by 2030 it wants to have 100% of Medicare services paid through some form of value-based payment system.
Payors historically follow suit with Medicare. Most already offer value-based payment contracts in the marketplace. McKinsey projects that by 2025 value-based contracts will cover nearly 65 million Americans, or 22% of insured lives, up from 15% in 2021.
It’s clear: the movement towards value-based care is underway and will continue. 3<br>
slide4. Three Reasons Why Providers Should Be Focusing On Value-based Care THE BIG BOYS ARE DOING IT
Some of the largest companies in America are spending billions of dollars to create an internal system that offers, and is betting heavily on, value-based services. A few examples:
Amazon recently agreed to purchase One Medical, a large provider of primary care, value-based services, for $3.9 billion! See What Amazon’s $3.9B One Medical Acquisition Means For In-Home Senior Care - Home Health Care News 4884-7099-9348 v.1 000117/02101, 4:16 PM, 10/27/2022
CVS acquired Aetna, a large health insurance company, in 2018, and continues to expand the health care services it offers, including in its pharmacy locations. See Public policy: Expanding access to value-based care | CVS Health
In 2020 Walgreens invested $5.2 billion to acquire control of VillageMD, and through that entity is rapidly expanding its value-based presence, particularly in in-home care. See Walgreens Boots Alliance Makes $5.2 Billion Investment in VillageMD to Deliver Value-Based Primary Care to Communities Across America | Walgreens Newsroom.
Just last week Walmart announced that in 2023 it will open 16 health clinics in Florida, located next to large Walmart stores, offering primary care, dentistry and other services pursuant to a Medicare Advantage contract arrangement with United Healthcare. See Walmart Health plans to open 16 more Florida clinics next year 4<br>
slide5. Three Reasons Why Providers Should Be Focusing On Value-based Care FEWER GOVERNMENTAL CONTROLS THROUGH THE VALUE BASED ENTERPRISE
The federal government recently created reduced regulatory standards to accelerate the migration of providers from fee-for-service into value-based contracting. These new standards significantly reduce compliance risks and obstacles to providers who are willing to accept risk. These new standards can allow your practice to function more freely, with fewer governmental barriers.
The reduced regulatory standards center around a vehicle called a “Value-Based Enterprise.” By contracting with a Value-Based Enterprise, providers can partner to enhance and leverage their collective ability to effectively compete for incremental revenues in value-based contracts.
One example as to how this can work is shown in the next slide. 5<br>
slide6. Physicians Working With A Hospital To Create A “Win Win” Result In Value-based Contracting Value-based contracting across a spectrum of risk offers new and exciting opportunities for medical practices to work in collaboration with hospitals and surgery centers through a Value-Based Enterprise, so that all parties have the potential to obtain incremental profits from their efforts. Here are a few possibilities:
Partner to create more sophisticated ambulatory surgical centers to accommodate the increase in more complex surgeries allowed to be performed outside the hospital setting
Market directly to employers, by-passing insurance companies
Participate collectively, as partners, in insurer risk contracting programs for specialty services 6<br>
slide7. Providers Need To Be Have A Plan For Value Based Care Migrating from fee for service to value-based contracting can be a formidable task unless it is planned and implemented properly.
Healthcare organizations planning to move to value-based care need to focus on establishing a system where providers collaborate and share patient information through technology platforms, and coordinate payments. Clinical protocols must be created, continuously monitored, and modified over time. Data must be harvested and utilized in a meaningful way to determine the best and most efficient types of care. 7<br>
slide8. Winners And Losers Entering into a value-based contract ultimately means taking some form of risk, termed risk-based contracting. In order to be effective at risk-based contracting, providers have to collaborate and work together in processes to become high quality providers. They must then leverage that value proposition with payors.
The Center for Healthcare Quality and Payment Reform (see 4 Steps to Successful VBP (chqpr.org)) posits that there are four steps for success in value-based care: (1) identifying potential avenues for avoiding spending without harming patients; (2) designing an approach to delivering services that can be expected to reduce the avoidable spending; (3) creating payments that give providers the ability to implement and sustain this new delivery approach; and (4) holding providers accountable for delivering the services.
The winners in this evolution of reimbursement reform will see increased profitability, while the losers will be struggling to maintain their historic levels or even to survive. 8<br>
slide9. Health Equity – What Is It And Why Is It Important? The Robert Wood Johnson Foundation defines health equity as meaning “…that everyone has a fair and just opportunity to be as health as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.”
Health equity is different than health equality. A physician can treat every patient equally and fairly, regardless of race, color or creed, and that may be health equality, but it is not necessarily health equity. Health equity plans address inequities in the ability to access the care they need in the first place.
CMS is beginning to focus heavily on the need for providers to have a program that promotes health equity as an important component of value-based care. Many health systems are developing health equity plans to address this issue. 9<br>
slide10. ACO Reach Model The First CMS Experiment In Health Equity The ACO REACH Model requires, beginning some time in 2023, that every ACO REACH participant create a written Health Equity Plan, revised on an annual basis, which must be provided to CMS. The purpose of the Health Equity Plan is to identify underserved communities within the ACO’s population and implement initiatives to measure and reduce health disparities for that population.
ACOs will have to report periodically to CMS to demonstrate their progress in implementing their plans and achieving health equity goals and may be penalized for not doing so. 10<br>
slide11. Conclusion Value based care is the future of health care. There will be ups and downs. Some companies will fail in their attempts to provide a successful and profitable product. Health equity will be an ever-increasing goal. However, the cost of healthcare cannot continue to rise unabated, and better care at lower costs, the goal of value-based care, appears to be the best potential solution to this massive problem. 11<br>
Frank Exposito, American Choice Healthcare Jonathan A. Fialkow MD, FACC, FAHA, Baptist Health Peter Young, Healthcare Strategic Issues Mike Segal, Nelson Mullins Moderator: Ed White, Nelson Mullins
November 3, 2022<br>
slide2. What Is Value-Based Care? Value-based care is a healthcare payment system that ties payments to the quality of care provided, and rewards providers for both efficiency and effectiveness. It has emerged as a clear alternative to the fee-for-service payment system. Value-based payment systems are designed to provide higher quality healthcare services for patients while lowering cost. This shift in payment methodologies is sometimes referred to as reimbursement reform.
The evolution from fee for service to value-based care is proving to be a long and tedious journey, but it continues to move forward. 2<br>
slide3. Three Reasons Why Providers Should Be Focusing On Value-based Care IT’S INEVITABLE
The cost of healthcare as a percentage of the U.S. gross national product has risen steadily for the past 20 years, and as of 2020 was 19.7% of GNP. This is unsustainable.
In 2020 there were 54 million Medicare beneficiaries; by 2030 there will be 80 million. CMS has announced that by 2030 it wants to have 100% of Medicare services paid through some form of value-based payment system.
Payors historically follow suit with Medicare. Most already offer value-based payment contracts in the marketplace. McKinsey projects that by 2025 value-based contracts will cover nearly 65 million Americans, or 22% of insured lives, up from 15% in 2021.
It’s clear: the movement towards value-based care is underway and will continue. 3<br>
slide4. Three Reasons Why Providers Should Be Focusing On Value-based Care THE BIG BOYS ARE DOING IT
Some of the largest companies in America are spending billions of dollars to create an internal system that offers, and is betting heavily on, value-based services. A few examples:
Amazon recently agreed to purchase One Medical, a large provider of primary care, value-based services, for $3.9 billion! See What Amazon’s $3.9B One Medical Acquisition Means For In-Home Senior Care - Home Health Care News 4884-7099-9348 v.1 000117/02101, 4:16 PM, 10/27/2022
CVS acquired Aetna, a large health insurance company, in 2018, and continues to expand the health care services it offers, including in its pharmacy locations. See Public policy: Expanding access to value-based care | CVS Health
In 2020 Walgreens invested $5.2 billion to acquire control of VillageMD, and through that entity is rapidly expanding its value-based presence, particularly in in-home care. See Walgreens Boots Alliance Makes $5.2 Billion Investment in VillageMD to Deliver Value-Based Primary Care to Communities Across America | Walgreens Newsroom.
Just last week Walmart announced that in 2023 it will open 16 health clinics in Florida, located next to large Walmart stores, offering primary care, dentistry and other services pursuant to a Medicare Advantage contract arrangement with United Healthcare. See Walmart Health plans to open 16 more Florida clinics next year 4<br>
slide5. Three Reasons Why Providers Should Be Focusing On Value-based Care FEWER GOVERNMENTAL CONTROLS THROUGH THE VALUE BASED ENTERPRISE
The federal government recently created reduced regulatory standards to accelerate the migration of providers from fee-for-service into value-based contracting. These new standards significantly reduce compliance risks and obstacles to providers who are willing to accept risk. These new standards can allow your practice to function more freely, with fewer governmental barriers.
The reduced regulatory standards center around a vehicle called a “Value-Based Enterprise.” By contracting with a Value-Based Enterprise, providers can partner to enhance and leverage their collective ability to effectively compete for incremental revenues in value-based contracts.
One example as to how this can work is shown in the next slide. 5<br>
slide6. Physicians Working With A Hospital To Create A “Win Win” Result In Value-based Contracting Value-based contracting across a spectrum of risk offers new and exciting opportunities for medical practices to work in collaboration with hospitals and surgery centers through a Value-Based Enterprise, so that all parties have the potential to obtain incremental profits from their efforts. Here are a few possibilities:
Partner to create more sophisticated ambulatory surgical centers to accommodate the increase in more complex surgeries allowed to be performed outside the hospital setting
Market directly to employers, by-passing insurance companies
Participate collectively, as partners, in insurer risk contracting programs for specialty services 6<br>
slide7. Providers Need To Be Have A Plan For Value Based Care Migrating from fee for service to value-based contracting can be a formidable task unless it is planned and implemented properly.
Healthcare organizations planning to move to value-based care need to focus on establishing a system where providers collaborate and share patient information through technology platforms, and coordinate payments. Clinical protocols must be created, continuously monitored, and modified over time. Data must be harvested and utilized in a meaningful way to determine the best and most efficient types of care. 7<br>
slide8. Winners And Losers Entering into a value-based contract ultimately means taking some form of risk, termed risk-based contracting. In order to be effective at risk-based contracting, providers have to collaborate and work together in processes to become high quality providers. They must then leverage that value proposition with payors.
The Center for Healthcare Quality and Payment Reform (see 4 Steps to Successful VBP (chqpr.org)) posits that there are four steps for success in value-based care: (1) identifying potential avenues for avoiding spending without harming patients; (2) designing an approach to delivering services that can be expected to reduce the avoidable spending; (3) creating payments that give providers the ability to implement and sustain this new delivery approach; and (4) holding providers accountable for delivering the services.
The winners in this evolution of reimbursement reform will see increased profitability, while the losers will be struggling to maintain their historic levels or even to survive. 8<br>
slide9. Health Equity – What Is It And Why Is It Important? The Robert Wood Johnson Foundation defines health equity as meaning “…that everyone has a fair and just opportunity to be as health as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.”
Health equity is different than health equality. A physician can treat every patient equally and fairly, regardless of race, color or creed, and that may be health equality, but it is not necessarily health equity. Health equity plans address inequities in the ability to access the care they need in the first place.
CMS is beginning to focus heavily on the need for providers to have a program that promotes health equity as an important component of value-based care. Many health systems are developing health equity plans to address this issue. 9<br>
slide10. ACO Reach Model The First CMS Experiment In Health Equity The ACO REACH Model requires, beginning some time in 2023, that every ACO REACH participant create a written Health Equity Plan, revised on an annual basis, which must be provided to CMS. The purpose of the Health Equity Plan is to identify underserved communities within the ACO’s population and implement initiatives to measure and reduce health disparities for that population.
ACOs will have to report periodically to CMS to demonstrate their progress in implementing their plans and achieving health equity goals and may be penalized for not doing so. 10<br>
slide11. Conclusion Value based care is the future of health care. There will be ups and downs. Some companies will fail in their attempts to provide a successful and profitable product. Health equity will be an ever-increasing goal. However, the cost of healthcare cannot continue to rise unabated, and better care at lower costs, the goal of value-based care, appears to be the best potential solution to this massive problem. 11<br>