Editor’s Note:
This article is the latest in the Health Affairs Forefront series, Accountable Care for Population Health, featuring analysis and discussion of how to understand, design, support, and measure patient-centered, cost-efficient care under the umbrella of accountable care. Additional articles will be published throughout 2023. Readers are encouraged to review the Call for Submissions for this series. We are grateful to Arnold Ventures for their support of this work.
Over the past decade, health care providers and insurance plans have increasingly pursued value-based care models that are designed to improve patient and clinician experiences while reducing costs and improving quality to produce better population health. With more community and consumer engagement, these models have huge potential for advancing key consumer priorities, including affordability, effective care coordination and communication, data sharing, and providing whole-person care. However, progress has been relatively slow, and the opportunity to engage patients in their care has not yet been fully realized. As value-based care models continue to improve and evolve, the definition of “value” for consumers and patients must also be broadened to include reducing inequities in access and quality.
As consumer/patient advocacy members of the Health Care Transformation Task Force, a multistakeholder consortium committed to accelerating the pace of value-based care transformation, we strongly support ongoing efforts to move to a person-centered, value-based payment system that prioritizes strategies to achieve health equity. Here, we our vision for how individuals, patients, and families can be best served by accountable care models that center on individual needs and preferences. Meaningful, equity-focused, value-based care is a promising and necessary alternative to fee-for-service medicine. We also call for action to increase provider uptake of value-based care models and engage patients and communities in their development, implementation, and evaluation.
Addressing Health Inequities
In recent years, health care payers and professionals have leveraged value-based payment models to address health care disparities that perpetuate in the fee-for-service system and that undermined some communities’ health long before COVID-19. These models aim to address disparities by improving quality of care and incentivizing providers to partner with community-based services and workers beyond traditional clinical care.
It is well-documented that 80 percent to 90 percent of drivers of health are rooted in socioeconomic and environmental factors, including structural inequities, often referred to as the social determinants of health. However, in fee-for-service medicine, payments to physicians are almost exclusively tied to medical and clinical care (with incentives to maximize service volume), which are not necessarily aligned with the non-clinical needs that affect health outcomes. Many alternative payment models use fee-for-service as an underlying payment method. However, additional model design elements including care management fees, shared savings arrangements, and capitated payment can allow health care professionals to invest in services and benefits that extend beyond the clinic walls to respond to social needs affecting people’s health.
The Pathways Community HUB (HUB) Model, for instance, seeks to improve health outcomes for high-risk individuals by identifying and supporting people experiencing social and behavioral risk factors in a pay-for-performance approach. The model deploys community care coordinators (CCCs) – including community health workers, social workers, and nurses – to conduct community needs assessments to identify individuals experiencing a high number of risk factors, then link them to evidence-based interventions. The HUB Model primarily focuses on addressing risk factors at the individual level such as housing, smoking cessation, insurance, and employment. To reduce emergency department visits, most individuals will need interventions to receive ongoing primary care, help with medication, help with housing and assistance connecting to other social services. CCCs track each person’s risk over time through measures such as emergency department visits, hospital readmissions, and hemoglobin A1c, and payments are dependent on improved outcomes. Implementation of the HUB Model in Ohio and Michigan has led to reduced rates of low birth weight and preterm births for babies born to Black birthing people. Additionally, an evaluation found that high-risk birthing people without HUB care coordination in Ohio were 1.55 times more likely to deliver a baby needing a special care nursery or neonatal intensive care unit admission. The Ohio model evaluation demonstrated a 236 percent return on investment.
Another example is Blue Cross Blue Shield (BCBS) of Massachusetts’s Alternative Quality Contract (AQC). The AQC program, which started in 2009, features financial incentives to providers who improve on quality, patient experience, and total cost-of-care measures. After the first year, providers in the contract experienced an increase in quality scores for chronic care management and pediatric care. Beginning in 2023, BCBS of Massachusetts incorporated pay-for-equity incentives to reward not only overall improvements in quality, but advancements in health equity in several areas including colorectal cancer screenings, blood pressure control, and diabetes care. In a webinar hosted by the Health Care Transformation Task Force, BCBS of Massachusetts highlighted the importance of collecting race and ethnicity data to move from improving quality to reducing inequities and gaps in care based on demographic characteristics. The program is too new to have evaluation and impact data, but the Center for Healthcare Organization and Innovation Research at the University of California Berkeley School of Public Health is evaluating the program and will present findings in the near future.
Continue reading on Health Affairs to learn about coordinating team based care for improved outcomes and increasing affordability for patients.
