Provider Perspectives: Value-Based Care

The healthcare industry has been slow to fully embrace value-based care (VBC). To account for increasing granularity of quality metrics, value-based contracts have become more complex. Unfortunately, that complexity also makes it more difficult for payers and providers to align on VBC arrangements.

As the Quality Assurance/Improvement Officer at AdvantagePoint, Carol Ann Hudson understands the barriers that can prevent providers face from moving into new value-based care arrangements and programs. We recently chatted with Carol Ann about AdvantagePoint’s approach to value-based arrangements, the challenges she’s experienced, and how she thinks payers and providers can work together more effectively to support the expansion of value-based care.

This interview has been edited for length and clarity.

 

Edifecs: What portion of your enrollment falls under an APM arrangement? How do you determine where to deploy resources?

Carol Ann Hudson: Around two-thirds of our acute care markets are currently in our networks. Our goal over the next two years is to have everybody, all of our markets, in some sort of network. We struggle a little bit because we’re in rural areas, so we have to do a lot of recruiting of independent [practices] to get the number of lives up, to actually get payers to come to the table and talk to us and offer us something.

[But] we have resources to deploy. We have care navigators, care management, a CDI program for both pre- and post-encounter, and we have things to bring to payers. We think we present a really good case, and I can proudly say that for 2023 we did not lose money in any arrangement. We always hit our shared savings.

 

Edifecs: Would you agree that independent practitioners and clinics have become more sophisticated about and interested in value-based care?

CAH: I would. But I hear all the time from the [independents] we’re recruiting, “Oh, we would love to go with you, but we don’t have the staff to even be able to log into a portal and pull that list of HCCs that need to be recoded,” or whatever it is. The goal is for everybody to get under some [VBC arrangement] and to have help, and I think building large networks is the way to go.

 

Edifecs: It sounds like the programs are typically not integrated. Does that isolation make it easier or more challenging to measure performance?

CAH: More challenging. There’s data coming from all different sources [that is] not in any standardized format. We’re getting quality information from payers; we’re getting the risk adjustment stuff from our MA plans; we’re processing our own data from CMS or MSSP claims.

I’ve got a team that’s working in pre- and post-encounters using the Edifecs Risk Adjustment Clinical Suite. Everything’s so scattered. We’re implementing a new population health platform, but we have to teach the platform how to ingest the data from various places, because it all comes in different formats.

The future has got to be [data that is] somewhat centralized in a standardized format to help us manage those patients. Payers could have a platform that they could offer to independent providers [and deliver] actionable data at the point of care that shows providers quality, risk adjustment, even total cost of care for that patient.

 

Edifecs: There seems to be an underlying divide between core fee-for-service programs and the emerging value-based programs. How can we bridge that gap?

CAH: It’s complicated, and it’s really hard to engage with providers that really don’t understand [value-based care]. And I don’t think that payers totally know what they want either. For independents, [the key is] giving them the opportunity to have support, and also coming up with a model that’s going to be workable across the U.S.

 

Edifecs: Despite the good intentions behind regulation and compliance rules, it often becomes a box-checking exercise where organizations meet the letter of the law rather than the spirit of it. AdvantagePoint has made good progress on this front; what have you done, and how have those decisions played out?

CAH: Well, we’ve made the decision to invest. We built a CDI team, and we got software to enable us to be more productive in the CDI space. We built a care navigation team so we can actively reach out to patients. We have ADT feeds coming in, so we know when they’re going to the ED, when they’re going to the hospital, and when they’re discharged so we can reach out and make sure they have a follow-up appointment: all of those things that payers want us to do to help manage their members.

[The key is having] real-time data access at the point of care. But it’s got to be real-time: it can’t be from a quality report that was taken from claims and is three months old by the time we get it. If we put that in front of providers, they’re going to say, “I did that mammogram last month,” or “I coded that last month on the visit, and you’re telling me to do it again.” So real-time data is just as important as data integration.

 

Edifecs: We like to talk about “collaboration” as an industry, but we don’t hear a lot about “cooperation.” In order to truly cooperate, you need a shared understanding and awareness, and that depends on data availability. How have you been successful in creating that awareness?

CAH: I think that the cooperation between the payers and the networks like us, or with the providers on the provider side is great. I think that there’s value in the data that we’re given.

The key is just continuing to work together and for both sides to actually come to the table, because they both have the same challenges, and there is a common solution out there. We’ve been most successful when we’ve been able to sit down and work together with payers.

We keep talking about payers and providers, but the patient’s the most important person here. And we’re keeping patients healthier, we’re providing the right care, we’re making sure that we’re giving the right amount of credit for how sick the patient is—all of that comes together through collaboration and cooperation.

 

Edifecs: What would you either advise or ask for as a way to help reach across the aisle and make more progress?

CAH: I would ask payers to come to the table with an open mind when we come to you, or even consider approaching us. We may only have two markets in a given state, but somebody else may have multiple markets that we don’t know about. Payers could come to us and say, “Hey, we have this arrangement with [Organization] and we know that you have hospitals or markets also in this state. Would you guys be interested in working together?” Because you can be in more than one clinically integrated network, and networks can join together. That’s something I would like to see.

 

Edifecs: What is the first thing you want to hear a payer say that you can take back to your providers, whether it’s those small independents or Medicaid to convince them to participate in a VBC program?

CAH: We’re only looking for arrangements that involve downside risk because when we take the risk, we know that the upside reward is better. So we really want payers to give us those kinds of arrangements.

Let us help negotiate those terms of the MSR/MLR and then what we can take back to the provider is, “Here’s the proposal, and we were able to negotiate these terms. And here are the things that they need you to meet, but based on where you are today, here’s what we think that you’ll be able to earn out of this.”

That’s what [providers] really want: they want something in addition to their fee for service, for the extra work they’re putting in, [because] we’re asking them to do all these things: code this, make this quality measure and all that. That willingness to negotiate is what I like to hear from a payer.

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As we learned in our discussion with Dr. Adele Towers, interoperability can support more effective care delivery and better clinical and financial outcomes in VBC arrangements. But as Carol Ann makes clear, interoperability and real-time data exchange aren’t just key to better outcomes—they’re also essential to ensure the continued adoption and expansion of value-based care as a whole.