As healthcare accelerates its shift from traditional fee-for-service to risk-bearing, capitated models tied to clinical outcomes, it is crucial that provider groups and health systems support clinicians to focus even more on patients and minimize disruptions to care delivery.
To achieve a revenue cycle that flourishes from the very start, capturing a patient’s concerns all the way to the final coded experience, organizations require technology and services that prioritize time spent with patients and attentiveness to success metrics in value-based payment contracts, said Sandeep Wadhwa, MD, global chief medical officer of 3M Health Information Systems, which provides clinical documentation and risk assessment solutions to healthcare organizations worldwide.
Here, Dr. Wadhwa discusses trends driving the continued shift to value, the types of risk-adjustment methodologies that are important for this shift to happen, and the most important steps organizations can take to succeed in value-based care.
Editor's Note: Responses were edited for length and clarity.
Question: Current healthcare payment is trending away from the traditional fee for service and moving toward capitated models. What issues or trends do you feel are driving the continued shift to value?
Dr. Sandeep Wadhwa: The driving themes for insurers haven’t changed. They seek measurable health improvement for their population and the ability to manage costs. What we're seeing more recently is a resurgence of transfer of total cost of care risk. Insurers are finding receptive provider and health system audiences, willing to take both population health and total cost of care responsibilities. There still exists a healthy market between insurers and providers to optimize the fee-for-service environment with partial incentives and disincentives based on quality, but now there's more appetite to structure more inclusive arrangements with partial and full capitation. Payers are also finding ways to support their risk bearing providers with analytics, technology, and services to help them be successful. We are seeing this most actively in Medicare Advantage arrangements but also commercial and individual risk carriers establishing narrow network options. For insurers, such arrangements are attractive as they minimize their underwriting risk.
Second, I would also call out that this is an example where our market economy is working, with a ton of entrepreneurship and innovation. That, and private investment is supporting new forms of care by either supporting risk-bearing provider entities or firms that provide technologies and services to support health systems and provider groups.
A third driver has been the steady voice of CMS, and the Center for Medicare & Medicaid Innovation in particular, promoting value-based care and new models of provider-centered population health. I think many of the concepts and models originating from CMMI have jumped to the private sector where they have evolved and matured. Having CMS, and individual states to and increasing degree, signal their desire for population and value-based financing creates an environment for providers to innovate and adapt.
Q: What relationship do you see between the shift to value and evolving care settings?
SW: I would offer four strategies for how the value equation manifests itself in care settings. First, we're seeing a lot of horizontal integration in healthcare. When I served as the Medicaid director in Colorado, we had over 40 different provider types that we independently needed to think about. We are seeing multiple provider types being aggregated horizontally allowing patients an end-to-end experience across the ambulatory, acute, and post-acute settings of care. There is a lot of promise in this seamless care experience, when you have the means of population health under one horizontally integrated system.
Second, there is a resurgence in primary care. We've talked about the patient-centered medical home care delivery model previously, but I think there is now financing to back it, and you're seeing some exciting finance models with primary care groups receiving partial or full capitation
Additionally, the home is emerging as dominant setting of care. Retail has been radically transformed and shopping from home is firmly established. We've talked in the payer world about digital health for the past years, but I have historically viewed those services as a supplement to the primary provider relationship. With the pandemic, the home has not only redefined our work life, but how we receive healthcare. There’s a place for in-person care, but I don’t see us letting go of the convenience, comfort, and benefits of centering care at the home for both digital health solutions and virtual access to provider care. I’d also note that brick and mortar retail is related to this space as these retail centers can offer convenience and a broad range of community health services.
The fourth care setting strategy I’d mention is the rise of payers vertically integrating with providers. Health systems have been acquiring physician and other provider practices. That vertical integration is something that we're all familiar with, but payers have also been aggressively vertically integrating with provider acquisitions. This combination allows payers to not transfer risk to the provider but leverage their core insurance capabilities with the clinical care being under the same organization. Traditionally, this space was led by group health maintenance organizations or provider-owned health plans, but we’re now seeing national for-profit insurers and Blues plans owning practices.
Each strategy has its champions, and we'll see how it works for achieving optimal population health efficiently.
Q: A major element of value-based care is accounting for variation in populations and patients. What types of risk-adjustment methodologies are important in the shift toward value-based programs?
SW: Risk adjustment had been a tool that was important between governments and insurers to ensure capitated payment rates were covering expected costs of a population. Now that costs of care are increasingly transferred to the providers, providers are more aware of the importance of risk adjustment. Furthermore, providers are much closer to the patient than payers and have fuller clinical information. The formal language of a provider organization is much less around administrative claims and much more around other clinical languages, such as SNOMED, that center on clinical terms and diagnoses. Now we have providers wanting accurate risk adjustment and using these clinical languages to inform the risk adjustment tools. I think that's where risk adjustment is evolving to get more precision with this proximity to the patient and clinical care.
I also think that risk adjustment will incorporate not only clinical markers, but social and community risks that contribute to health disparities and inequities to ensure that resources are better matched to the population’s needs.
Q: How does 3M help payer and provider organizations work together as they straddle this change?
SW: Our technologies and solutions aim to define the language of value, payment, and accountability and we invest in maintaining those methodologies to not only measure outcomes but help risk-stratify populations and make sure payments are accurate.
3M is also centered on conversational artificial intelligence at the point of care. There is an equal interest in trying to maximize time clinicians are spending with patients and using technology to help capture that interaction and codify it, so we can get the next steps in the care process done seamlessly while preserving and giving more clinician time to be present and attentive to the patient. There’s great synergy between our methodology excellence and our support of the physician's experience in delivering outstanding care.
Q: In the context of changing payment methodology programs: With your background as a physician, how do you continue to keep the focus on the patient?
SW: My work with patients is largely in teaching the fellows and the residents. We'll use technologies to look up a question we have in real time. So I strive to try to consciously parse my time focusing on residents and patients, and then pause and engage with technology so that I’m overt in who is getting my attention. I sense the patients appreciate full attention as do the residents and the fellows! I try to be conscious about how to minimize interruptions or distractions that take away from being thoughtful and present, and connecting to people in a way that is good from a healing, therapeutic relationship point of view. Patients and the fellows respond differently when they feel they've got all of you in a visit. That's where I'm excited to see how this growing technology can support that unobtrusively. Where I see myself and the market moving is to preserve that intensity of presence, but to have the technology working for me in the background unobtrusively and in parallel.
Q: The COVID-19 pandemic shed further light on the health disparities that exist in America. What more can healthcare organizations do to better understand the social determinants of care affecting their patients and adjust improve health equity?
SW: There is a maturing lens of equity driven by the learnings from COVID-19, but also from the events of racial violence and disparities this summer, that have changed the way we look at how we deliver care. I think we knew much of this intellectually, but now there is emotion, tangibility and a sense that it is incumbent on all leaders and members of health care organizations to approach our work with an equity lens. We're seeing that every day and now in how we're distributing the COVID-19 vaccine to vulnerable populations. It's not perfect, but I am encouraged by how it is at forefront and organizations are actively taking steps to address the situation and prioritize.
Now there is a wonderful opportunity for our technologies, systems, incentives, and culture to support equity. In my conversations with health systems on vaccine distribution, leaders are sharing best practices, the electronic patient portal was an efficient first way to schedule vaccines, but it is now being complemented with a phone tree for patients who don’t access electronic visit portals, and systems are further leaning into new proactive outreach to community organizations. I'm very hopeful that we're not just bringing an equity lens to our thinking, but now to our systems.
Q: What are the most important things that an organization can do to succeed in a value-based environment?
SW: One part of the solution is being attentive to the success metrics in the value-based contract. You've got a top line, you've got your efficiency, your quality, your experience metrics and regulations. But I would offer there's something equally important around succeeding in value-based care: It's thoroughly incorporating the voice of the patients or members in the design, in the goals, in the ongoing management of the value-based care effort. That stakeholder engagement is the piece I want to call attention to, and by stakeholders, I mean the patients themselves. There's opportunity to be more structured and formal and go beyond experience and satisfaction surveys to more formal stakeholder outreach, inquiry, and incorporation of their needs and priorities.
As we move financing and accountability closer to the provider health system, there's also an opportunity to bring the people served to co-lead/co-participate/co-own this effort. The presence and voice of the person we're serving shouldn't be assumed, it should be co-equal. If we want to be successful, if we want to get outcomes and priorities that matter to people, I think structured stakeholder participation and engagement is just as important as the regulatory and financial accountability metrics.