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Welcome, everyone, and good afternoon. My name is Allison Jones. I’m Director of Program Strategy and Management here at the Alliance for Health Policy. We are a non partisan, non-profit organization dedicated to helping policymakers and the public better understand health policy, the root of the nation’s health care issues, and tradeoffs posed by various proposals for change.
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We’re thrilled today to presenting our webinar Perspectives for Media on value based Care in 20 24.
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The Alliance has served as a trusted educational resource for the health policy community for more than 30 years, and today’s webinar will explore the current value based care landscape, highlight anticipated policy discussions for the coming year, and identify key considerations for reporter and other media experts.
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We’re excited to showcase the range of Health Care Policy Stakeholder perspectives on value based Care as part of today’s event. And hope this discussion will help you all in your work to advance solutions for improving our health care system.
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Before we get started, I want to take a moment to thank our events sponsor.
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Today’s webinar is made possible with support by the National Institute for Health Care Management. We are grateful for your support of this program and for all you do to improve health care by advancing diverse perspectives on health.
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I also want to share a few quick logistical notes.
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As always, we invite you to follow the Alliance for Health Policy on LinkedIn to stay informed about upcoming events like this one, you can also find us on Facebook and YouTube.
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Today’s panel will have a Q&A section at the end, and we encourage you all to be active participants.
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So, please feel free to share your questions throughout the event.
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You should see a dashboard on the right side of your web browser that has a speech bubble icon with a question mark.
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You can use that speech bubble icon to submit any questions you have for the panelists at any time, will collect these, and address them during that Q&A.
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If we don’t get to your question, please don’t hesitate to reach out to us at Info at all health policy dot org. And we’ll do our best to connect you with additional information.
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With that, I am so pleased to introduce our moderator for today’s webinar, Susan Denser.
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Susan Tensor is President and Chief Executive Officer of American Physician Groups.
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A non-profit organization representing more than 360 physician groups focused on patient centered co-ordinated and integrated health care that is accountable for both cost and quality.
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Susan is a highly respected health policy, thought. You’re a frequent speaker. And an author of Commentaries in the New England Journal of Medicine Catalyst, the American Journal of Public Health, and others to name a few. You can read more about Susan background and the bios of the other panelists on the Alliance website. And with that, I’ll turn it over to Susan.
2:35
Thank you so much, Allison, And hello to all of you joining us for this webinar today.
2:40
It’s a real pleasure to be moderating this discussion on value based Care in general, of course, and then the outlook for value based Care in 20 24 and beyond.
2:52
I’m delighted, particularly, because our organization is singularly committed to advancing the cause of value based care. All of our medical groups, all of our roughly 200,000 physicians, are engaged directly in various value based care models.
3:07
So this is a subject very close to our hearts, as it is, I know, to all of the hearts of our panelists today. And they are indeed a very distinguished bunch.
3:17
So I would like to begin by having them all briefly introduce themselves to you joining the webinar today.
3:24
Let me start with one of our very distinguished speakers per about Raul Bova. Would you introduce yourself to the group?
3:33
Apigee, thanks for having me here today. Suzanne. My name is …, I’m the Chief Strategy Officer at the CMS Innovation Center. Really excited to be on a panel with everyone today.
3:43
Great. Thank you Provost so much for being with us. Sarah Levin. Please introduce yourself as well.
3:49
I good afternoon everyone. I’m Sarah 11. I work on the Ways and Means Committee. I am the deputy sector for the health said. Look forward to this conversation today.
4:00
Great. Thanks Sarah so much for joining us and David Pittman.
4:05
Hi. My audio issues Or just back in time David Pitman, my my title is director of regulatory affairs and communications for the National Association of Nikos. Nikos represents about 430 ACOs nationwide covering about nine million people. I specifically worked on Regulatory Affairs, mostly for us, but also health background journals, the first 10 or 12 years my career. I worked as a journalist, working for local newspapers and trade organizations and the trade newsletters in DC. But my last job was working at Politico recover, start up their health coverage and into our providers before leaving an event neighbors for about six years now.
4:48
Right. David comes to this topic with multiple perspectives, current and past. Thank you, David, for joining us. And finally, we’re really happy to have with us also, onto Choudhry. I’m sorry, would you introduce yourself?
5:01
Yeah, thanks, Susan, And thanks, everyone, for joining us today. My name is on Shoes Choudhry, Vice President’s Policy Development Strategy to Blue Cross Blue Shield Association, which is the Trade Association, which represents 33 Blue Cross Blue Shield companies around the country. Have been with the Association for 19 years and May, and then close to value based care, or the air and excited to get to have the opportunity to spend some time with you today.
5:28
Well, thank you, aren’t you? And as you can see, we’ve got a great series of perspectives to bring to bear on this question of, with our value based care.
5:37
To start us off today, I’d like to do some grounding discussions of what we mean when we’re talking about value based care.
5:46
All of us have the, uh, probably the unfortunate task sometimes of explaining to other people what we do and why we do it.
5:54
They have usually no idea of what we’re talking about, and what we have certainly found is when you say the word value to regular old human beings, they kinda think you’re talking about something that’s at the corner maybe of k-mart and dollar general value proposition in healthcare.
6:11
Right. And we know that that’s not what the attempt is behind value based care. So clearing up a lot of these misperceptions. Frankly, and it’s not just consumers of regular people.
6:23
It’s sometimes policymakers, as we know is really, really important.
6:27
So to get to that level Let me ask all of us to fantasize for a moment that I am some kind of weird alien creature, marchionne, or whatever.
6:37
I’ve landed on Planet Earth with the instructions of trying to take back two.
6:43
My folks back home, some understanding of what the heck we’re talking about when we say value based care. So I land here, I have almost no understanding of the US healthcare system as it is.
6:55
I don’t even know if it’s really a system, frankly, but I wanted to understand if what this whole concept is all about.
7:03
So, I’ve been handed a list of instructions from my bosses back on Mars or wherever, and they tell me, the first door I’m supposed to knock on is somebody at someplace called the Innovation Center at the Centers for Medicare and Medicaid Services, which leads me to knock on the door of Perverts.
7:23
So Purvey, I’m an alien.
7:26
Tell me how you explain value based care.
7:30
Well, first, I’ll start by saying, Susan, though it might have been the best opening question I’ve ever gotten. And I thank you for moderating today’s panel, because sometimes on these topics, don’t make us laugh it off. And thank you for taking it up. And thank you to The Alliance for Health Policy in particular, for hosting today’s event. I think it’s a great addition to Value Week, and I hope that many of you that are online today have joined, and hopefully are gonna join them. Any discussions that have been continuing on taking place over the course of this week, I think. you asked a great question and a really foundational one value based. Care is a term that we use to describe healthcare that is designed to focus on the quality of care and individual receive their care, experience, and provider performance.
8:12
When we talk about value based care, the Innovation Center, and, you know, we test new models that try to innovate in terms of payment and care delivery. We emphasize integrated and co-ordinated care, meaning healthcare providers work together to address a person’s, physical, mental, behavioral, and social need. The whole person care. Providers are treating an individual at the whole person, rather than focusing on just a specific health issue or disease.
8:39
Currently, our fee for service payment systems aren’t designed to meet the needs of patients in that holistic way. And oftentimes the financial incentives in the fee for service system. And maybe many of your members, you know, have indicated this to you as well. It’s not always optimal for physicians and other healthcare providers who want to provide that type of person centered or whole person care, and focus on those patients that need more time.
9:01
We know that the fee for service system on tight financial incentives to the volume of care delivered.
9:07
Sometimes it can drive unnecessary procedures, are duplicative tasks care, that’s an Anthony more expensive for people onto the system and honestly contribute to fragmentation for patients and families.
9:17
And, you know, there are some, really, some recent data, I think, that really underscore the complexity that people are facing as they’re trying to navigate the health system.
9:26
For instance, nearly 30% of Medicare beneficiaries of 2 to 3 chronic condition, 22% have 4 to 5, and 18% have six or more.
9:35
Do you think about the daily, complex conditions that are beneficiaries are living with? And then the proportion of beneficiaries that are seeing five or more physicians annually has increased from 18 to 30% or from 2000 to 2019. So, not only are people dealing with more complexity in terms of the health challenge that they face, but they’re also trying to navigate multiple, different providers across different settings.
9:59
More than ever, I think we need new paint ways of paying and delivering care well. What should value based care look like for a patient, and what does that weren’t actually translate to for an individual? So, I’ll just share a quick example of how at the Innovation Center, we try to use value based payment to support that more person centered care.
10:16
We have a vignette of a patient, a beneficiary in one of our kidney care models, and she was being served by one of the providers and a kidney care model. And she found out that she needed to start dialysis and check sheet, use the word that she found it was crushing, because she reported thinking of her of her own mother, who would wake up at three AM, three times a week to receive dialysis. And that’s what she thought she was going to have to do because it’s provider, was Anna value based payment model. She’s actually able to work with that kidney care provider to receive home dialysis.
10:46
Luckily, she has support at home from her husband, which allows her to receive dialysis home more easily.
10:52
Can do this multiple times a week while eating dinner, watching TV spending, time with their family or her friends visit, And amazingly, she was also able to continue working as a director of child care services and a social service agency before she retired. So it’s not a payment that is driving what happens and value based care, but it should be the quality outcomes and experience. And you asked about the Innovation Center in the role that we play.
11:14
We test new approaches to care delivery and payment, and the common goal of these models are to improve patient care, ensure that people have access to high quality care, and to reward healthcare providers for delivering that high quality and cost efficient care. So, you can think of the innovation center as the R&D component of CMS.
11:32
And our vision is really to build a health system that achieve equitable outcomes through high quality and person centered care, and use a combination of incentives, and standards to try to accomplish those goals. Are models, and our tests can include things like upfront investment for infrastructure and data, that give providers the ability to identify, for instance, the sickest patients like who is most likely to be hospitalized or re-admitted, and how can we get ahead of that and help.
11:56
Our models can include regulatory flexibilities that let providers care for patients in lower, cost or more convenient settings such as the home or in the community, and provide more services through non physician.
12:08
Models include electronic tools and data. We know that data is really important for providers to co-ordinate care, for instance, between primary and specialty care providers.
12:17
Then, of course, our models include payment innovation, that give providers more stable and predictable payment and incentives that reward better outcomes, higher quality, and a better ancient experience.
12:29
Tell us up there, but I’ll just give a little plug for those of you that want to learn more on the CMS Innovation Center. Recently launched a new value based care spotlight with patient and provider stories, and a lot of other helpful information on how to put in a plug to visit that site if you’re interested in more of our work.
12:46
Great. Well, thank you, Purpa.
12:49
So, as an alien, my head is spinning as I try to absorb all of this.
12:53
But what I’m taking away from this is that although earthlings probably go to the doctor’s sinking, that they should always get quality health care, and that it should be focused on them as people. That doesn’t always happen.
13:11
And part of the reason it doesn’t happen is because of the way we pay these healthcare providers. So we need to figure out ways to pay them differently.
13:21
So they’re incentivized to do these things, like provide quality and be really focused on patients.
13:29
And I guess what I’m also picking up is that you’re involved in something that does this through the Medicare Program, but the briefing documents I’ve read shows that there’s a lot of money floating around the system that is not Medicare or Medicaid.
13:47
It’s private payments.
13:49
So I’m trying to understand how this movement relates elsewhere, so that means I’m going to go knock on another door, which is that on share.
13:59
And I here aren’t you have something to do with other money, that’s not government money.
14:06
So, explain to me value based care in that context.
14:12
So, thank you, Susan, and thank you for kind of setting the stage on how this works on the government side of things. And, you know, we are Blue Cross Blue Shield companies. collectively, our Plan serve 1 and 3.
14:28
Americans. And so, we do have a very large role in the health care system, working closely with the government, and then also working closely with employers as well, who looked at Blue Cross Blue Shield for insurance. And, you know, we collectively serve, as I mentioned, the one in three Americans. And what we try to do in our models, to the extent that we can is fine alignment with, in some cases, with what the government may be doing. And the types of models are portable laid out.
14:54
But if there’s not going to be perfect alignment, there’s going to be a very similar framework for how we structure value based care programs.
15:01
And so, it’s the same sort of core principles around improving quality, over quantity of services provided, making sure that there’s a focus on prevention, and rather than, it’s a proactive approach to care, rather than a reactive approach. To care. Making sure it’s the right care in the right setting, and ideally, there’s a primary care foundation in the value based care model. And, or, at the very least, if it’s not a foundation, because it might be focused on a particular specialty care model, then, at least, there’s that connection. And there’s a team of providers that are working together to provide comprehensive care, co-ordinated care, across settings and stages of life.
15:43
And So as a health plan, you know, one of the things that we do, in addition to paying and then maybe looking at different ways to pay different way for this type of care, excuse me. We also were able to provide resources to practices that we partner with, or to hospitals that we partner with. And so we have a lot of data in our fingertips as our plan.
16:04
And so, part of what our role is, where we can help practices, and hospitals as providing data. So they can see the entire, sort of picture of the patient’s care. So, when a patient, you know, enters the four walls of, as, let’s say it’s a primary care physicians practice and they, you know, are treated a patient centered way, I’m gonna say a medical home type of model. And then they go somewhere else for a particular service. Or maybe several months later, they, they go to another location, we’re able to provide that data back to the provider who may not see that whole picture. So, that that patient care can be looked at in a holistic way.
16:41
Also, providing information sharing in the form of tools, like electronic medical records, and other sort of support tools that can help a practice better take care of its entire population. On the payment side, as we talked about the structure, the other big part of this is payment. And how do we move away from fee for service? And so, there’s a variety of different approaches that you will take in looking at different models, and a lot of independence. First, on the, the readiness of the physician practice, or maybe the hospital that we’re partnering with, how advanced they might be in these types of models, taking on any sort of risk outside of a fee for service arrangement. So, fee for service, you know, Do you perform a service, you get paid, but then the risk part of the models, Which is kind of where some of the incentives come in.
17:29
And, these value based care models is around taking on some risk for a population where, you know, if, you know, provide care, and it leads to better outcomes better, Patient satisfaction for either A fixed amount of money. For your entire population, or maybe it’s bonus payments that are given to a provider that has demonstrated those outcomes, then that’s where some of the additional dollars come in. Or, in some cases, they might not make those benchmarks, But that’s kind of where the incentives are to continue to drive improvement, and continue to make sure that patients are getting the type of care that they need. And so, these models take many different flavors in the private sector.
18:09
But, typically, they are focused on some of those chronic conditions. And also looking at some of the higher costs, conditions where, you know, there is the evidence that backs some of the medicine. There’s the measures there to make sure that we’re measuring the right things and a fair thing to measure provider on. And then, obviously, there’s the patient satisfaction piece, which we always want to build it or two to make sure the patient gets what they’re needing out of the whole experience.
18:38
Right. Well, thank you and share on it. Now, as the alien, I’m starting to understand a little bit more about this, but I still have a lot of questions.
18:46
one of the questions is, I read that no body in the US system actually has to do any of this.
18:56
Actually move to new pin models can actually move to really be incentivized around quality and patient centeredness.
19:08
So I guess now I’m going to go over to what I understand is a body called Congress’s menu charging passing laws to make things happen.
19:18
I’m going to ask Sarah Levin explained to me how what is the role of the legislature in all of this, and why is it that the legislature has made all of this happen?
19:33
What is the actual role in of the Congress, in facilitating or making happen, value based care in the government programs, or even all the way over into this private sector activity that we’ve just heard about?
19:52
So, thank you, and thank you so much for, for having me here today. And I, you know, where Congress, you know, I have to say something like this, but, you know, I speak on behalf of myself, and not on behalf of my chair and the ranking member of the committee for whom I work, or, you know, the whole committee itself, or every Democratic Congress just for myself. But thank you again, and, you know, I would say a lot of the messages that forever and onto already described, are things that we start think about all the time when we’re talking about policy. And what, what Congress does is it makes us, right. So it sets the rules of the road for all of these discussions.
20:31
And it has different roles You know that’s the overall broad view, but different ways It works in Medicare, Medicaid, and in the private sector. Right. Because Medicare and Medicaid or governmental programs, there are other governmental health programs as well. And then the private sector, the Congress, gifts, the rules of the road and about how the private sector operates from a federal sense, obviously, say temporal as well.
21:02
And so when we think about when we’re thinking about health policy and what we think about value, I think I would echo what the previous panels have described. But really we’re thinking about this from a patient perspective.
21:14
But, you know, what is, how can we try to create these rules of the road so that a patient can get the right care at the right time at the right place? And, you know, always thinking about because we’re always thinking about budgets and making sure that we’re paying appropriately, you know, thinking about how much the soft costs and thinking about what the prices and making sure that there are fair prices. And, and to ensure that costs are not overtly high. And so a lot of what was discussed by permanent aren’t you are the things that come in under let you know, as layers underneath that. Right? We think about how to make policies to improve affordability how to make policies to improve, access and improve equity and to make sure all of those kind of drivers are in a patient centered way. and.
22:06
The way that there there are lots of different programs in the federal government that try to incentivize moving towards that direction.
22:16
Lot of that was, you know, there was a lot of discussion about value in the 2010, someone in the build-up to the ACA. And the bills are two which created the Center for Medicare and Medicaid Innovation and a lot of value based programs, and then in … for Accountable Care organizations. And then also again, and MACRA, which was a bill relating to physician payment reform.
22:43
And these kind of these, a lot of the discussion was trying to move towards value based, move towards, you, know, right, Care, right? Price, improve quality, lower cost, that, kind of, you know, bending the cost curve. There’s a lot of that discussion. And I think that that is what is.
22:58
So that’s a lot of that.
23:02
It is kind of entrenched now into the systems, right? We’re talking about all the work that CMMI has done to try to bring into what they have learned, to their value based models, and try to improve upon that, all the work that she was talking about with, you know, with expanded coverage. There’s more people getting health care and how to make sure they’re your best serving Their needs. And I think the role of Congress is, trying to say is, particularly now, after the focus on the value of two thousand and TEN’s, is trying to think about, OK, what, what is next? How do we make the next steps forward, so that we can improve value? and learn from what we’ve learned in the past decade and, and move forward.
23:46
OK, thank you. Well, again, I’m starting to gain a greater understanding of all of this, but I still have a lot of questions.
23:53
And I guess the main thing is, what I’m picking up, is that this move to value has been mainly a question of changing incentives for a big system. That, as I understand, it, costs.
24:07
a lot of money, spends more on health care than any other country on this planet, on a per person basis.
24:14
But it’s been about changing incentives.
24:17
Nobody’s really been forced to do this, mandated to do this.
24:21
There hasn’t been a national law, compelling everybody, to move to value based care.
24:27
So it’s been kind of voluntary.
24:30
I guess I’m scratching my head to understand, you’ve all discussed how this has been going on for quite some time, trying to understand what’s been accomplished from all of this, moving in this way of really changing incentives. So I’m gonna go knock on a final door which is that of David Pittman and I hear tell that he’s spent a lot of time covering all of this as a journalist.
24:55
Now, he’s at an organization that has a major stake in this movement to David, explained to me what’s happened and how pervasive value based care is. And frankly, what’s been accomplished.
25:10
Well, thank you, Susan, and I was a little flustered because I had audio issues before. I didn’t have a chance to thank the Alliance for Health Policy and … for hosting this event.
25:19
Actually, when I was a reporter, I covered a lot of health policy policy panels and sessions, and on Dirksen hearing room. And it’s, it’s kind of surreal to me on the opposite end of this. There’s been a lot accomplished Susan.
25:37
And I think when people hear the term value based care or some of these some of these terms, I think maybe they get a little what’s the word kind of?
25:52
They think it’s sort of a buzzword and baloney and overused and, and value based care is, it’s a term that is, you see it, It’s overused the point where it’s cliche, but it really does have meaning, and there’s a lot that has been accomplished.
26:07
You know, earlier this week, CMS put out numbers. It’s, that showed, participation in the three biggest ACO models, It’s the highest we’ve ever seen.
26:20
It’s, it’s, it’s the highest percentage of fee for service patients in medicare that we’ve ever seen.
26:28
Close to 15 million patients.
26:31
Every year, there’s this organization called the Health Care Payment Learning Action Network that surveys participation and value models across all payers, including commercial, Medicaid, as well as Medicare.
26:45
Most recent report showed that the Participation Value Models was the highest, it’s ever been, it’s, it’s close to 40%.
26:51
Um, and this is having a real, I think that’s, it’s, it’s, it’s not necessarily translating very clearly in, you know, the dollars and cents, and that’s because it’s just really hard to measure.
27:07
There’s, there’s, what we call spillover effect, right.
27:11
Like win-win Health Systems, physician practices, they start to add care co-ordinators, they start to add after hours, call line. So, people will call them, rather than, the Emergency Department will start to improve access and all sorts of ways. But they don’t just necessarily do that for certain patients they did for all their patients. So, when, when, as many people start to get into these payment models and payment arrangements.
27:43
It’s begins, really hard to quantify what savings are attributed to this CMS program versus that commercial payer.
27:51
Um, the, the, the per capita of spending on health care in this in this country has its, while it’s still far higher than what it should be, it’s it’s flattened out and been pretty much what, what, what overall inflation has been for the last several years, and that, again, it’s hard to quantify this, but it has a direct effect, or direct relationship to what, you know, people on this call have been doing, the policy, making, the practices we’ve been making, implementing an actual care. And that’s that’s not really appreciated or necessarily picked up, because it’s really hard to measure.
28:31
And, you know, the CBO, the Congressional Budget Office has said, you know, some of the, the, the, the, the declines, the flattening of Medicare spending has been because of care co-ordination.
28:47
This stuff is really the work we’re doing, and it’s having an impact, and I wish it were translate more concretely to people.
28:58
Because it gets, it gets hard to measure and it gets lost in cliche, terms and overused jargon, and that gets thrown into press releases, because we think it gives you that warm fuzzy feeling We’re trying to elicit. But some of this stuff for all the reasons that we’ve talked about, is really having an impact.
29:18
OK, OK, well, as I say, the alien is set, is continuing to ground.
29:24
We’re understanding of how all of this works, but I guess to stay on your last point.
29:32
Some of my briefing documents picked up on the point, you mentioned, David, which is that when people get asked to actually add this up in terms of dollars and cents, some of the conclusions are kind of that. The whole effort has been underwhelming.
29:48
And forever, I want to come back and knock on your door again, because one of these reports I read was from something called the Congressional Budget Office that basically said, in the first 10 years of the innovation center, actually more money had been spent on the innovation center than had been changed.
30:08
saved through Medicare Changes. Now, is that back to the problem that David just talked about? Which is that it’s really hard to measure this stuff, and it’s hard to capture.
30:21
Everything that goes on in the system that’s not uniquely related to individual payment models, are helped me understand why there’s more happening here than sometimes seems to show up in concrete evidence. Because that was the gist of what David just saw.
30:41
I’m happy to talk a little bit, you know, the first 10 years of testing and learning at the Innovation Center, I think a lady, very strong foundation for us to actually lead the way in the next decade towards broad and equitable system transformation. Each of the models that we’ve launched, we’ve had over 50 that we’ve launched since the beginning of the Innovation Center has yielded really important policy and operational insights.
31:05
that really help us address not only those continued challenges with cost and quality, but with also saying, you know, how we advance equity and patient experience?
31:16
In the second decade, we’re taking those lessons learned and focus, and we’re focused on using everything we’ve learned so far, to test those kinds of models. And we really believe that we’re seeing that change. We’re, you know, we’re seeing changes in care delivery that improve quality, and reduce costs, and helps improve outcomes in the long run, and we’re also thank David talked about fail-over, were seen at those changes might spread are spreading to other parts of the system.
31:41
Maybe in ways that were not quite yet detecting. And to your point, is, And what are some of those other changes that are happening? You know, we recently published a paper, in the New England Journal of Medicine Catalyst on the types of care delivery changes that have taken place in our model. Because we want to understand what’s actually happening when providers are delivering care, if I wanted to value based payment, What’s changing per beneficiary? And we actually found that our model to date are associated with significant care, delivery experimentation, and changes. And so our next step at the innovation centers to focus on what isn’t it, isn’t working, and to lean into, and to disseminate those changes and care delivery that, we know improve quality, and outcomes, and, or reduce costs. And I’ll just say, from that retrospective review that we did of our own work, three major themes emerged first. We found that participants are model participants across a very wide range of different programs use, a common set of care co-ordination and other person centered strategies to deliver care.
32:38
We found that they were actually delivering more team based care. They emphasize things like patient navigation again, to help people, you know, navigate that complexity in the system, and they focused on things like care management, using risk assessment, and stratifications that you can identify those patients. That might be the highest need in your practice.
32:55
Second, we also found that the types of practices, practice changes, enable buyer models, allow providers to actually tailor care about it and we’re talking about person centered care. That is, in essence, what it allowed them to do to meet their own patient needs.
33:07
I think this is a really important point against, and probably for your members as well, as providers themselves are experiencing and reporting high levels of stress and burnout, we hope that value based care models can help unlock that flexibility and innovation for them as well.
33:21
We found providers and our models are also reporting experiencing that kind of flexibility in how they deliver care. For instance, they were using data sharing as part of our model to support quality improvement efforts, and interesting, they also supported stronger partnerships with other providers, So even if a trader is not enough value based payment model, they’re actually saying, we’re communicating more, and Indian Indifferently on, around the patient, and their care journey. And then the last, you know, theme was around evidence of changes, extending beyond Innovation Center Model. Again, picking up on that theme of spillover that David talked about, in some cases we were finding in our model test are time limited, usually about five years, somewhere, and longer.
34:03
Is on that model for impacting people. Beyond those that were served just by the model of, just, you know, not just our Medicare beneficiaries of Medicaid beneficiaries are in a model, but to others as well on the health system. And that provider, And even after a model. Where, in many cases, the reporting wanting to maintain those care delivery changes after a model that I think over the last decade, we’ve had some really significant impacts as part of that value based care movement on the health system. And we demonstrated how those payment changes support delivery system, transformation and change.
34:37
Great. Well, thank you.
34:39
Well, one avenue of value that we haven’t discussed so far, and again, the alien picked up on this briefing documents is, there’s another big program called Medicare Advantage, which exists alongside the traditional Medicare program.
34:57
And most of the models that we’ve been talking about so far, I’ve heard you all talk about it in that traditional program.
35:05
So, there are variations on the fee for service program, whether it’s the Medicare shared savings program, or other models, but this other avenue, which is Medicare Advantage.
35:19
I haven’t heard you all talk much about, And from what I understand, that, that is a very diverse program.
35:25
In itself, it is not monolithic Because It is delivered by private plans.
35:31
But let me go back to on Chu and ask about how it’s a Blue Cross Blue Shield Association, where you do have a lot of private plans are participating in that program. How do they see that as part of the value equation?
35:48
Yes. So we see here is, as you noted, Susan, there definitely is, historically, there’s been more of an emphasis on the commercial side.
35:57
But MA is a significant part of the, the business, as well as if we are going to make sort of sustainable change over the long run, and have these models stick. You know, you have to do it across multiple lines of business, and government programs as well.
36:14
And so plans have been trying to take some of the foundational elements from there on their commercial, commercial business, and fold that into the MA model. Although sometimes to be, you know, because the population needs might be slightly different. Is something that we’re, you know, we’re still still kind of, learning, or trying to figure out exactly what are the components. We do see that I’m a cipher our plans that have been structuring value based contracts, there. You know, what we do try to do to make sure that, you know, there is to make it easier on the providers that are also serving patients across multiple lines of business. Is trying to look for alignment to see, like, where, what the provider might already be doing.
36:58
And so, it could be, you know, processes that our structural changes or incentives that were tied in on the commercial side. We try to extend those that can be alignment. It was like the Medicare Shared Savings Program.
37:12
If there are participants in that demonstration, you know, looking to see where they have certain capabilities that they might might as unique support’s needed.
37:22
On the Medicare side, relative to commercial. And then, also, looking to see how we can build in, it is, say, maybe there’s more focused on a physician, physician practices. How can we tie this in with an ACO that might be able to take care of some of the more complex needs that go beyond just primary care? And that’s when you start to see more of the specialty care needs. That might be more prevalent among the Medicare population. And so, and, particularly, if these are smaller practices that, in small independent practices, you, know, helping link them with an ACO and form kind of a medical neighborhood, so to speak. So, it’s not just the medical home, but it’s, it’s community providers that are working together on that.
38:04
Then, on the payment side, you know, it’s kinda continuing to try to evolve away from fee for service as much as possible. And whether that’s, you know, looking at the, the healthcare, the Learning and Action Network that’s been around for a couple of years now in the framework that was created there, Making sure that they’re the right incentives in place and trying to align with the different categories. So there’s a category one which is fee for service with no linked to quality or value. And there’s the slightly more advanced wishes still based on a fee for service chassis. But there is a link to quality value then. There’s category three, which is, and that’s when you start to build in more of the risk and still built on fee for service, but more risk is being incorporated.
38:48
And then category four, I’m moving more towards like, a true population based payment for that group of providers that we’re working with. And so we’ve been trying to do create as much alignment as possible with the learning and Action network categories and kind of where CMS’s priorities are on the Medicare side for trauma.
39:09
So one way to think about it, and I’m gathering is so category for which if you use population based payment, other people would also say capitation.
39:21
You think about the model under which, for example, the Kaiser Permanente system plans are organized. That’s capitation.
39:30
You can have capitation through Medicare Advantage. You can have capitation in the commercial side.
39:36
like Kaiser Permanente has that notion of the provider entity being entirely at risk for the cost of the care and entirely accountable for both the cost and the quality of care.
39:51
That’s the Holy Grail that you’re describing, all that Syria based You all are trying to drive the system to. Is that fair?
40:02
I think, I’d say, yes.
40:04
And I think that’s an important part, though, is, it’s making sure that we, as the health plan, are providing supports to help them succeed, though, as well. And that’s where the data sharing, that’s where, whether it’s the structural supports in the office, giving, an electronic medical record, the practice didn’t have before. Or it could be clinical decision support tools, or it could be even just connections with, you, know, just other resources in the community or that. The plan sometimes plans offer staffing. So, it could be a nurse that can help with care management on-site. So, it’s, it’s not just putting them at risk and then saying, All right, here’s your money, go. It’s alright. Here’s your money. We’ve got the population, and it’s agreed upon goals that are set also for that. So it’s not just the payer, say, OK, this is what we’re giving you, figure it out.
40:53
It’s agreed upon goals and dollars, But then, what supports can we provide to help you succeed? And I know CMS does that, as well.
41:01
And in many of their models, and I think that’s, that’s a big component of that, is important and value based care, especially as the farther along the continuum that you go with increasing the risk. While some of those practices are, hospitals might be more sophisticated to begin with there, we still can’t forget, you know, making sure that we’re supporting as well, too.
41:25
Well, we’re going to take some questions from the audience in just a few minutes, but before we get there, let’s do kind of a lightning round, because I want to hear from all of you.
41:36
What do you think is ahead this year that will pertain to the topics that we’ve been discussing around value based care?
41:44
So what action steps or other events should people anticipate this year as we think about value?
41:52
Now, we know we are in an election year and sometimes not my champing in election years, and sometimes a lot happens in election years.
42:01
So what do we think is ahead And I’m going to start off, Sarah, with you, from the perspective of the Congress and particularly the House of Representatives.
42:11
Yeah, And thanks for that question. I think that that, we’re still trying to find from last year, So thinking ahead, we’re still thinking towards how to get through March, so that we can ensure that programs are, are funded.
42:24
And part of that, and part of that discussion we’ve had discussions in the past on this is related to, you know, increase payments for Medicare providers, at least in the traditional Medicare side, bleed into Medicare Advantage as well, or participating in value based care models. And this has actually been it’s up for reauthorization. It’s actually been difficult to try to get over the finish line because I think that, as I had said earlier, there’s been huge conversation about value based care.
42:57
In the 2010 and then you know all the discussions on how were, we want, you know, my organization is trying to improve value X and this is why I think that Kobe kind of changed the discussion for awhile right. We’re focusing on the immediate needs of the pandemic. There was obviously a huge monumental change and effects in the health care system in the way people received care. And, I think it’s an opportunity now to have to kind of think through and use kind of the shifting conversation from what, it wasn’t the 2000 and tends to what it is now, to try to think through, what does value mean. And how do we want to move forward and have to re-orient the conversation back back to value? And maybe in a different way, right?
43:41
And thinking about all the different assets that come through value, thinking about access of care, there’s so many different policies we can think about to improve access of care, I’m thinking about affordability. And there’s so many things that we can do to think about how to improve affordability, and make sure people can get access, and get the care they need when they need it. And then, an overarching, all of that, certainly thinking about how to make sure that assault equitable and they’re obviously every policy that comes through Congress relating to health care you can fit into those buckets. So, I think once we, I think it’s an opportunity now for a re-orientation to try to think through what is the, what is value in the coming decade. Now that we’ve had this experience with over a decade with the Medicare Centers for Medicare and Medicaid Innovation innovations for CMMI firm. Now, we’ve had some time with the new physician payments. Now, we’ve seen Medicare Advantage has grown to from when, you know, almost doubled. In the past decade, is now the majority of the Medicare program now that the private market is doing a chain.
44:47
Talking about value based and frisks arrangement models in a different way, now that we have a vertically, much more vertically integrated system. Think a lot has changed in the past decade and it’s an opportunity to have to think Through how we want to look at this and what we can do to move towards that. Again, overarching view of right place right time.
45:07
And a place where that, you know, really right price. Making sure things are affordable, accessible and equitable.
45:16
So I think a moment ago you’re alluding to the question of the Advanced Alternative Payment Model bonuses which are bonuses that go to clinicians participating in traditional Medicare, and it’s a bonus that they get on top of the regular Medicare fees for being in the Specified Advanced Alternative Payment Models.
45:40
That bonus, of course, historically has been 5%, but it was cut last year to 3.5%. on what’s On the Table.
45:49
Now for 2024, is cutting yet again, down to 1.75%, and only extending it for a year.
45:58
So, stepping back, it looks like there isn’t a wild enthusiasm, necessarily, for, at least for the onus methodology in terms of getting providers interested in value based care.
46:13
So, I’m wondering, what does that signal about how, seriously these issues are taken in Congress these days?
46:21
Yeah, it has been a big challenge. I want to say something that, you know, my bosses always been a big promoter of value based care, so it is frustrating and disappointing to think about that how challenging. It was challenging to get the slash and half last year, or the, or it wasn’t quite an half slash last year, That’s even more challenging to get, thinking through how we’re gonna get advanced APMs. Reauthorize again for, for this year, they’ve already expired as you. Now. and trying to think through making sure that we have incentives in place for for providers to take the risk to take the leap, into and make the investments into alternative payment models that are driving towards value. and I think that that’s why it’s, it’s really it.
47:05
It’s challenging and, you know, a little bit disappointing that we’re having this kind of That it’s so hard to get those over the finish line, but I think that it’s also an opportunity to, again, reframe the discussion and think about what value is and try to think about how. What the next iteration of value, how we can make sure. This is, again, that, that part is one component of one of Medicare, right, making sure that individuals participate in and pants alternative payment models, which is a really important goal. But there’s also thinking through, as you said before, how do we improve value Across Medicare? Across the healthcare sector? And, And how, what we need to do to reach those goals.
47:49
And so, while it is, it is frustrating, I will say, is we’re knee deep into these negotiations. Currently, to think about, OK, well, you know, this is, this, is one pillar that we’ve had. And the value in moving towards value. What are the next pillars? We need to build to continue that March, And what does that work? Or how does the next iteration of value? What does that look like, and towards, in, terms of, legislating.
48:16
Well, I promise I’ll come back to the rest of you for some quick predictions about what’s ahead, But we also did promise them questions to the audience. So let me ask Allison to surface a few of the questions that have come in from the participants in the audience, also.
48:33
Right, we have one here for the group. Would appreciate it if Susan, …, and others can weigh in on what we may see for MACRA in the coming year.
48:44
OK, so that goes back to MACRA and I think it’s fair to say that certainly, from our perspective, that APG, we don’t anticipate a lot of big changes in macro this year, it’s a would be a big lift to overhaul MACRA, even though we think it’s needed.
49:02
We see more efforts to kind of tee up a larger set of changes, possibly next year. I would just say that we think that MACRA, in many respects, has kind of outlived its usefulness.
49:16
It was very important at the time it got us out of a rut that the whole system wasn’t around a prior formula for setting payment, but it was enacted in 20 15, and it’s it’s 10 years and a lot has happened in value based care and other initiatives.
49:33
So we’re expecting lots of discussions around possible ways to re-invent macro and repeat it for the next decade, but I’ll leave it there. Anybody else want to weigh in on that?
49:47
Sarah, I guess I didn’t get back to you as well.
49:51
I would say that, so I think about this. I was on a panel about how to move on to the next generation of of MACRA when I just came back from my maternity leave for my daughter. Who is almost six. So, I feel like this discussion is continuously ongoing.
50:10
And, uh, I think that there’s a large discussion of how do we, how do we think about physician payments going forward. Right? What worked and MACRA, what didn’t work? And MACRA, how do we harness what the opportunities are? The things that macro is a big right and wanted to get rid of the SGR, which is like giant cuts to physician payments that happened and cause that. Congress had to deal with 6 every 6 months year. There were so many different iterations, we needed to get off that roller coaster, and the idea was to move towards value based payment. And it had some goals about having, you know, the idea was that most providers and health care system would be an Advanced Alternative Payment models right now that a goal has not been breached.
50:55
But it was, it wasn’t good goal. And frankly, the discussion during macro, a lot of the providers and conversations were coming in, we’re saying, you know, we, we want to do more value. We want to, you know, we want higher, higher quality and we can do, we want to be paid for, containing our costs and you know. So, we want to share in those savings and try to figure out how to move this ball forward. I think the discussions a little bit different again, a change in Kobe, in healthcare Inflation and, and just the staffing shortages.
51:25
I think a lot of the focus lately has been on things like, How do we make sure, you know, people keep people afloat? And so, again, it’s a new opportunity to have those larger discussions. We’ve had lots of discussions on the Hill, bipartisan, lead by Kimberly. These types of discussions need to be bipartisan, needs to be by cameras, to make real change real. And I think there’s a commitment for everyone to have those kinds of discussions. We’ve had talked to lots of stakeholders, but I gotta tell you, there’s no consensus on what’s next. I think around the macro. There’s lots of consensus. We need to get away from SDR and we launched with value. There isn’t a lot of consensus on how to what the next iteration should be. And those conversations need to continue because it needs there needs to be. Again, it’s a new opportunities to think about how we should be going forward.
52:15
And understanding the reality of the traditional Medicare landscape has changed from the conversations that we had when we when we undertook the macro discussions.
52:27
And just to re-iterate the final point, there are still a whole lot of healthcare systems sitting outside of value, and a lot of physicians sitting outside of value and firmly rooted in fee for service.
52:39
And they will have to be part of the conversation about re-inventing NAFTA. So let’s take another question analysis. We wanted to just, then at least a couple more, if we can, then some additional protections.
52:52
We have one more here, Value based care has been focused in primary care, how do you see specialists being integrated or incentivized to be part of value based care?
53:03
Great. Well, profile. I know that you’ve been doing a lot of thinking on that, and at the Innovation Center, and some of the models really are tailored more at the specialists component as much, certainly as primary care, but how are you thinking about that at this point?
53:21
I’m happy to talk about that for a minute. We agree. We think it’s really important for all of our providers to be engaged and value based care. A lot of our models have been focused on primary care, and I think, as you said it earlier, that it’s really important that we think about primary care as the foundation of our health care system. Right. High performing health systems have strong primary care, and so that’s always been on a robust part of the innovation centers portfolio. But, we know that that’s not the only place people receive pyramid head, up, statistic that. I shared earlier about the number of, you know, company, A chronic condition that beneficiaries have, the number of positions that we’re seeing. And so we know that there needs to be better connections and integration between primary and specialty care.
54:03
So, over the last few years, we’ve actually developed and I won’t go into all the details here and a four prong specialties, care strategy. And how do we take a really holistic, comprehensive view across the health system? Really thinking about, what’s a patient’s journey like through the health system, across primary and specialty care. And then how are we testing innovation, whether it’s new model, ways of providing data, to foster that kind of integration and co-ordination and collaboration. So, we are looking at ways of providing data to accountable care organizations, providing new kinds of data at a primary care physician, so they can identify high value on specialty providers in their area that they can refer their patients to. We are also, we all kind of a Request for Information that we released last summer, when we’re thinking about then the Next generation, episodic based payment model for the Innovation Center. And what that looks like? And we got, We got a lot of robust responses And engagement on that truly informing our work. They’re moving forward, and then we also are looking at some ways of bringing specialists more directly into value based payment programs.
55:08
And then the last is really thinking about our overall broader strategy around accountable care, and really getting all of our beneficiaries into what we call accountable care relationships. So they’re receiving a team based on that team based care with providers and responsible for the cost and quality of their care. We know there’s a lot of opportunities to think about how specialists are also integrating into and interacting with our accountable care organization. So a multi-pronged view and knowing that not every clinician or physicians sits in the same place in the patients, are moving through the system in different ways. And so we really need at the Innovation Center to be innovating both from model and data perspective.
55:49
Great, thanks so much, Barbara.
55:51
Will, in just a few minutes, we have left. I want to go back to our predictions or at least some analysis of what we think was a hetzler this year?
56:00
And if there are some of you who I’ll call on now, we’ll take it just about a minute each, that, with all help us to get that subject on the board, but also end on time. So, David, let me ask you, What are you anticipating for the balance of this year in the realm of value based care?
56:20
Well, it’s a little awkward with Sarah and … on the call, as well, But, absolutely.
56:26
The, the, the Advanced APM Incentives that you talked about have been talking about, are absolutely on the table, and some little watch for, this is a call for, for press and media, A lot more coverage and attention goes, the physician payments, but that that APM incentive is absolutely something to keep an eye out for. But, as as, as soon as Sarah talked about you, to, to Susan, a lot of efforts to try to think about how to reform incentives, to encourage participation and some value models, it’s currently, that’s the, all the participation of the incentives are, geared toward to speak for service. So, how can we sort of flip that and make it more advantageous more carrots for, for APM participation, watching, for other ways, it’s, per had mentioned, on ways to bring in more providers into some of these models. We …
57:22
ways to bring in rural providers, specialists, long term care providers, All these, sort of non traditional physician offices and hospitals.
57:34
one thing also think about, or you know, to ask more questions on, is how do we, how do we pay providers within MA and commercial plans? A lot of attention goes to what is paid to the, to the, to the plans. But how do those plants then turn around and contract to pay their providers that?
57:55
That’s a way to recognize and reward value. So let’s keep an eye out and try to ask questions on that. So I’ll stop there.
58:04
Great. Thanks so much on choosing a sampling of Marshall plans.
58:10
That said, say, this year.
58:13
I think a few things jump out. There may be unique from, you know, what David just mentioned. And I think a lot of commercial plans, specifically like lacrosse for shell companies, were really looking at the health equity side of things and how to incorporate health equity more effectively into value based care models. So that it’s not, you know, just a couple of measures that are out there that are being measured, but it’s actually really embedded in the models.
58:38
We’re also looking at, as, we all know, that there’s a shortage of behavioral health and mental health providers, and primary care through collaborative collaborative care models by primary care physicians have taken on some of those responsibilities. And there are models designed around those to integrate behavioral health into primary care and in a different way for that.
59:04
Additional care and then that type of care. And so how can we better support providers there to address some of the behavioral health needs in this country. But doing it through the construct? A lot of value based care model And then I think also just the role of telehealth virtual care, you know just technologies as care delivery has changed. The pandemic changed a lot of it and just, the way that people access to health care system are, there are different types of value based care models that are out there. That we need to start taking a look at.
59:33
That could be effective in delivering high quality care, effective care, but at lower costs and any momentum from the pandemic for somebody’s alternative delivery models like, Telehealth. Is there something there, that value based care side for those models, too?
59:52
Well, speaking from the standpoint of a full alien here, who has listened to this conversation, certainly were, I an alien, I would come away with a much better understanding of the issues than when I landed here on Earth.
1:00:07
I do want to thank post both our cast of Earthlings, who explained all of this to them so well, and all of you in the audience, we hope you’ve benefited from this really whole holistic wide ranging conversation about the value of value based care. So with that, let me turn it back over to Alison to close us out.
1:00:30
Great. Thank you so much Susan, …, David, Sarah, and … you for joining us for this important conversation, and thanks to all of you in the audience who took the time to be here with us today. Before we go, we want to hear from you. We appreciate you taking a few minutes to complete a brief evaluation survey, and you can find that link in the chat, and you will also be receiving an e-mail later today with that link.
1:00:52
Finally, I want to make sure that all of you in our community are aware of our very exciting news, which is today, Claire Hsien has joined us as the Alliance’s new President, and CEO.
1:01:03
We’re so thrilled to welcome Claire and this new role, and you’ll be seeing more of her in the coming months. And we encourage you to sign up for our e-mail list to receive the latest updates and stay connected to what we do next.
1:01:13
As a reminder, a recording of this webinar and additional materials will be available on the Alliance website. And this concludes today’s event. We look forward to seeing you at Future Alliance Gatherings. Thank you.