VBC Symposium 2023 | Innovations in Value-Based Care for Complex Populations

Top takeaways included:

1. Focus on Empowering and Elevating Providers. The companies that are successfully delivering care to complex populations are those that are focused on empowering and elevating providers to fill in gaps in care; such entities also succeed on cost and outcome goals as a result. These companies primarily focus on primary care providers (PCPs), nursing homes and related front-line providers. The panelists who focus their efforts on primary care do so in the belief that primary care can have the greatest impact on outcomes. Traditionally, primary care has been delivered within the four walls of a PCP’s office, with fee-for-service (FFS) reimbursement. Companies take different approaches to moving outside of this traditional model: Some focus on extending services outside of the PCP’s office to fill in gaps in care, such as deploying nurses to the home. Others seek to enable PCPs with data and resources to identify patients with complex needs and to better advocate and care for those patients once identified. Other companies seek to take tasks off PCP’s plates, enabling them to spend more time on patient interactions that drive better outcomes.
2. Patient Engagement Is Critical to Success. To be successful in value-based care models with downside risk, companies must be excellent at patient engagement. Accordingly, when working with complex populations, the panelists discussed how there is significant focus on engaging patients, building a person-to-person connection, understanding patients’ needs, developing trust and providing patients with care where they want to seek care. Many successful companies utilize nonclinical personnel in this process, including community health workers and community health partners. The importance of patient engagement is also why many successful companies organize their models around PCPs, with the panelists discussing how patient engagement and, in turn, positive outcomes increase when a trusted PCP is involved.
3. Addressing Social Deteriments of Health in Value-Based Care Models. For individuals with complex conditions, social determinents of health (SDOH) also impact outcomes and costs. We have seen a greater willingness in Medicare and Medicaid to think about what should be funded to achieve better outcomes. The panelists thought this was an important policy shift, with one noting that risk-bearing models allow companies to reinvest surpluses back into the community and fund resources that impact SDOH, such as transportation, food and air conditioning.
4. Differences in Full-Risk Value-Based Care Arrangements in Medicaid versus Medicare. The panel also touched on the differences between Medicare and Medicaid and how companies think about full risk in these programs. In Medicare, there are two levers that companies can pull to be successful: the revenue lever (e.g., more accurate and more complete coding) and the cost lever. However, in most Medicaid programs, there is only the cost lever since risk-adjusted premiums are not a feature in most Medicaid managed care programs. Moreover, the difference in how medical loss ratio (MLR) is defined at the state level versus the federal level can make value-based contracting difficult, as many state Medicaid programs do not include quality initiatives in their MLR definition. As a result, value-based care in Medicare Advantage (MA) is well established, and parties are well versed on value-based care. This is not necessarily the case in Medicaid, which has increased levels of complexity because of state-by-state differences, lower funding levels and, in many cases, less knowledge about value-based care. There is significantly fewer value-based care deals in the Medicaid space today as a result. One panelist noted that value-based care arrangements in Medicaid remain at the beginning stages, which presents challenges but also presents room for innovation. Another panelist observed that because there are very slim margins in Medicaid compared to MA, successful companies in the Medicaid space must be very strong on operational execution.