As scientists, policymakers, and experts from around the globe have tried to make sense of the novel coronavirus and its impact on our health care system, they have created a wealth of scholarship and written pieces on the pandemic. To better understand the role of value-based initiatives, in particular, I took a close look at 35 articles on the topic and curated some of the most cogent findings on issues ranging from the financial health of primary care, to telehealth, population health, patient monitoring, and the future of value-based care. A crisis can also create opportunities, including the opportunity to bring together insights and knowledge that had gathered under the surface, and thereby make vital, lasting progress in reforming our nation’s health care system.
The pandemic has created unprecedented financial challenges for the healthcare system. These challenges are especially difficult for primary care providers. This group generally operates on slim margins under normal circumstances, but COVID-19 has made it near impossible for them to succeed under the dominant compensation system. Many practices have seen their revenue streams slow as stay at home orders and fears of infection keep many patients away from the office. At the same time that revenues are dropping, primary care providers are also being asked to move into a new role on the frontlines of the pandemic.
Almost overnight, telehealth, population health, and patient monitoring have changed from useful initiatives into essential capabilities for an effective practice. Emergency stimulus packages from the federal government have provided some relief for providers, but these will likely prove to be stopgap measures that will not solve the more fundamental challenges posed by the pandemic. As the number of cases once again rises and the threat of further waves of the virus in the fall loom, it has become clear that the best way to ensure the survival of independent primary care providers is to accelerate the transition from fee-for-service (FFS) to value-based care.
To its credit, CMS addressed several of these suggestions in its April 30th Interim Final Rule. While changes such as removing all COVID-19 costs from calculations of shared savings and counting telephone visits towards attribution are welcome, there are still more adjustments that can be made to ensure the continued success of the Medicare Shared Savings Program (MSSP).
Twenty-nine of the thirty-five articles highlighted the importance of telehealth, underscoring its central role in primary care during the pandemic.
According to CMS, more than 9 million Medicare beneficiaries received care via telehealth between mid-March and mid-June, as stay at home orders and fear of infection kept many patients out of the office. This unprecedented shift in care delivery was made possible by the expansion of reimbursement for telehealth services spearheaded by CMS.
While it is likely that telehealth will continue to play an important role in primary care going forward, it is unclear what changes and waivers granted by the Public Health Emergency (PHE) will persist in the long term. Without reimbursement parity, many independent practices will not be able to offer telehealth services. As Forbes Healthcare contributor Rita Numeroff points out, these practices risk losing patients to large companies such as Amazon or CVS Health that are expanding into the telehealth space. For practices in an ACO, losing these patients will also decrease their overall patient attribution, and, in turn, their shared savings amount.
CMS should take action to ensure ACOs face minimal challenges in setting up telehealth infrastructure. We have heard from many practices that part of the issue with telehealth are start-up costs. While the FCC offered $200 million dollars worth of grants, few of our providers were able to access this money. ACOs, especially those considered low-revenue, should have access to an ACO Investment Model (AIM) style program that helps cover the initial cost of getting set up with telehealth. CMS just announced an AIM style program called CHART for rural ACOs. This is a step in the right direction, but this is more than just a rural challenge.
Congress and CMS should also allow telehealth parity to continue for all practices in ACOs after the PHE expires. Under normal circumstances, only ACOs using prospective attribution are eligible for parity, but it would be simple to expand this provision to all ACOs. Historically, the argument against offering parity has been that it would be too expensive for Medicare, but because ACOs are accountable for total cost of care, they would use telehealth only when it added value.
In their most recent IFC, CMS changed its attribution methodology by allowing telephone (audio-only) codes to count towards plurality. It also clarified that any primary care visit provided through telehealth will count towards attribution.
While we support these changes, we also recognize that they have the potential to harm smaller or less technologically developed ACOs. These smaller ACOs are now at risk of having their patients attributed to larger ACOs. Accurate attribution of patients is vital to the financial viability of ACOs, and CMS must take proactive steps to make certain telehealth does not disrupt this process. Attributing patients based on care patterns over the length of two years rather than one could help remove distortions caused by COVID.
Additionally, CMS could limit the attribution of new patients to only those patients living in a county where the ACO previously had attributed beneficiaries for 2020. This is a necessary safeguard since many states have allowed out-of-state providers to provide telehealth visits for its residents. By taking steps to make certain that telehealth growth does not disadvantage smaller ACOs, CMS will encourage greater participation in value-based models and greater investment in telehealth capabilities that will keep patients safe from COVID-19.
A pandemic is a population-level event that requires a population-level response. Value-based models and ACOs specifically are better prepared to provide this type of population health monitoring and response than are providers who participate only in FFS.
Population-level data collection and analysis can be an important tool in determining which patients need to be contacted, assessing who is at heightened risk for a disease, and understanding the overall spread of a disease in a community. Many ACOs, including Aledade’s, already have population health monitoring infrastructure that can readily be adapted to COVID-19 monitoring.
In fact, because of the population health infrastructure that was already in place, we were able to create worklists that allowed providers to reach out to their most vulnerable patients in a matter of days. Myers and colleagues highlight how similar population health data systems have been used by Oak Street Health, a national network of value-based primary care centers, to monitor COVID-19.
Because an ACO’s revenue depends on health outcomes at the population level, investing in this infrastructure makes financial sense. The revenue of FFS providers, in contrast, is solely dependent on the amount of care they provide, meaning there is no financial incentive to monitor or attempt to improve health outcomes at the population level. Additionally, this dependence on volume means that if patient volume decreases, as it has across the country, independent FFS providers are at risk of going bankrupt, and thereby being forced to close their doors or sell their practice. On the other hand, as Murphy and colleagues point out, value-based models are significantly more resilient to changes in volume and can therefore focus on responding to COVID-19 at the community level.
CMS can take steps to support the population health function of ACOs during the pandemic. Some smaller or newer ACOs may not have the money on hand to invest in their data infrastructure. CMS can support these ACOs by providing advance payments as it did under the discontinued ACO Investment Model. ACOs would be able to use this money to begin tracking and using population health data to slow the spread of COVID-19.
Patient monitoring is another hallmark of value-based care that has grown increasingly important as a result of COVID-19. ACOs thrive by being proactive about their patient’s health.
The relationship between certain chronic health conditions and severe COVID-19 has been well documented. For this reason, chronic care management (CCM), principal care management (PCM), or remote patient monitoring (RPM) can play an important role in keeping patients’ illnesses controlled even when they can’t see their doctor. By managing a patient’s chronic conditions, we can decrease the risk of patients experiencing complications if they are infected with COVID-19. Additionally, CCM can help keep patients out of the hospitals, freeing up hospital resources to treat patients with acute illnesses, such as COVID-19.
Although pure FFS practices can be reimbursed for CCM, they are less likely to do so because a patient being hospitalized has no financial consequences for the practice. They are also less likely to have workflows that support coordinated care because there is no incentive to hire that extra RN or care manager.
As Kevin Chen, CEO of ChenMed, explains, providers in value-based arrangements have a strong financial incentive to monitor chronic conditions and take high-value steps to improve the patient’s condition. Additionally, value-based models can free practices to provide services that create healthcare value but are not reimbursable by CMS or other payers. Stephanie Quinn of the AAFP uses a game of checkers with a patient suffering from loneliness as an example of the type of non-traditional care that can improve health outcomes but is only financially viable under value-based frameworks.
At a time when, as Kazberouk points out, it is more difficult than ever to care for patients, adequately managing complex chronic conditions requires the financial incentives and organizational focus on chronic conditions that value-based arrangements create.
CMS should allow new ACOs to apply to join the MSSP in 2021. Citing challenges of using 2020 as a benchmark to which future years can be compared in order to assess value added, CMS has announced it will not accept applications for this cycle.
As Travis Broome, our SVP for Policy and Economics, explained in a Health Affairs blog post, now is a time when we should be encouraging more value-based care, not closing off one of the best opportunities to enter the space. Benchmarking challenges could readily be addressed by using 2019 as BY3 and trending this forward to 2021 to create the benchmark.
COVID-19 has exposed many of the weaknesses of the American healthcare system, FFS compensation being one of the most glaring. By protecting value-based care models from some of the worst financial consequences of COVID-19, we promote a more effective pandemic response and free primary care doctors to do what they do best, provide high-quality care to those in need.