Overcoming skepticism about value-based care

May 23, 2016 / By Kristine Daynes

Hospitals and physician practices are skeptical about the real value of value-based care. A Frost & Sullivan study for 3M found fewer than half of providers agreed that value-based care reduces the cost of patient care (45 percent). Even fewer believed that value-based reimbursement is better for patients than traditional fee-for-service business models (40 percent).

Ouch! Clearly payers face a steep challenge to show how value-based care is good for patients. At least most providers agreed that value-based care improves the quality of patient care (62 percent). That’s a start.

How predictive analytics helped one payer collaborate better with its ACO physicians

One way for payers to reverse the skepticism is by helping providers, especially physician practices, gain the competencies to succeed with value-based care. I talked with the program director at a Midwestern health plan whose VBC program is growing to 15 ACOs this year.

She said that early in the program there was some frustration about ACO performance. Data fatigue among physicians put them at risk of overlooking important information. Her internal case managers felt they had to “spoon-feed” information to them.

Case managers, too, were overloaded. Although the health plan had a web-based analytics dashboard, it was not practical for case managers to view the patient profiles for all members in the ACO, or even all at-risk members. Furthermore, there was almost too much patient outreach. Patients complained about redundant case management calls from the health plan, facilities and doctors’ offices.

The health plan decided to refine their case management approach. It is a model for other health plans who need more “bang for their buck” from investments in analytics and personnel.

The most important refinement was the choice to focus on persistent high needs individuals (PHNI). While many case managers target super-utilizers for intervention, studies show that greater than 75 percent of super-utilizers will lose that status within 12 months and approximately 85 percent of them within two years.

Using a 3M predictive model, the health plan identified members most likely to remain high utilizers and for whom case management could change the outcome (removing catastrophic conditions and malignancies, for example, and excluding high-cost pharmaceuticals).

The second-most important refinement is that the health plan shared the PHNI lists directly with ACOs, primary care physicians and health coaches. This was a deliberate tactical decision. Feedback indicated that patients listen more to their primary care physicians that they do to the insurance company or ACO. So it was important that physicians and health coaches on the front lines could access the PHNI lists and use them for case management.

The health plan educated ACO physicians and staff on the predictive methodology, showed them how to use the PHNI lists, and followed up promptly with the ACOs once the model was released. The response was immediate.

“Our ACOs are very list oriented,” said the program director. “They love to work a list, and the list of PHN individuals is a very positive sort of list. It is actionable, because it is patient-centered. I think that is what resonated with them. They truly get how it supports care management. They truly get how it helps their patients. And so this is a list that has a really positive impact. It gives them something very actionable.”

The PHNI list doesn’t replace the online analytics portal. But it does replace the tedium of skimming through member information. Rather than review every patient profile, case managers and physicians can review first the members on the list—sometimes only one or two per physician.

I was told of one physician who agreed the patient on her PHNI list had persistent high needs and guessed what conditions and types of utilization would show up in the patient profile. Surprise! When the doctor checked the profile, she was shocked to find a high-cost imaging procedure and prescriptions for a condition diagnosed by another physician. Just as important, she now knew to reach out to the other physician and coordinate care more effectively.

That type of case management experience needs to happen more often for physicians to adapt to a value-based world. It is a kind of collaboration that can overcome skepticism. It gets managers and health coaches ahead of utilization trends. It shows physicians where their efforts have an impact. It focuses on patients as individuals. It supports primary care. This helps providers see the benefit of VBC to patients and the bottom line, not question whether all the effort is worth it.

Kristine Daynes is marketing manager for payer and regulatory markets at 3M Health Information Systems.

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