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By David L. Morris, EVP & Chief Commercial Officer of Cedar Gate Technologies
Primary care has been hurt by the pandemic. The American Hospital Association estimated a financial impact of $202.6 billion in lost revenue for the country’s healthcare systems due to COVID-19. By July 1 of last year, 41% of U.S. adults delayed or avoided medical care, per a Centers for Disease Control and Prevention (CDC) report (1). The impacts of patients deferring clinical care early in the pandemic, and again amid the Delta variant, are still being determined. Still, initial data and feedback from physicians paint a picture of more severe issues resulting from less access to treatment. Contrast the impact of deferred care with the data on value-based care models where the emphasis is on early and intensive interventions—the benefit is clear. Early interventions are vital for patients and reducing overall healthcare costs for payers.
PCPs are on the frontlines – and the best positioned to identify early indicators of deteriorating health. However, in the break-and-fix model of fee for service, PCPs are often placed in a reactionary role, and not fully connected to long-term patient outcomes. So, how can PCP insights be leveraged to focus on patient outcomes and long-term cost savings? Amid advancing healthcare technologies and treatments, and skyrocketing costs, PCPs can embrace value-based care and align with its focus on early intervention to thwart dangerous and costly issues.
Finding the Value in Value-based Care
Value-based care for providers is effective in driving early intervention, which results in demonstrable and sustainable healthcare savings. This is especially relevant when considering the continuing rising expenses related to healthcare. For example, in 2016, a study on primary care spending in the United States showed total healthcare costs increased from $810 billion to $1.6 trillion. Additionally, specialty care accounted for 75% of healthcare spending in the United States.
Value-based care requires identifying health risks and chronic conditions to intervene early. For PCPs, it means pairing their expertise with best-in-class, high performing quality specialists who can most cost effectively drive outcomes in the specific areas where the patient is most vulnerable.
Rather than being paid based on the number of provided services and visits, value-based care incentivizes PCPs have available underlying clinical and SDoH data to prioritize care and intervene, appropriately, steering patients to the most effective treatment options or specialists, lessening, mitigating and preventing advancing chronic or more severe conditions taking hold. One of the most effective and rewarding transitions to value-based models involve providers moving their fee-for-service business into partially or fully capitated business models, receiving a risk-adjusted per member per month payment. The benefit to the patient is treatment programming focused on prevention and the future. The benefit to the payer is decreased costs associated with necessary and aggressive interventions, while PCPs establish predictable and consistent sources of revenue, enabling them to build practices of medicine driven by care.
Technology Supports Transformation
What does it take for PCPs and Payers to succeed in value-based care? Comprehensive believability-weighted data, analytics and reporting supporting both the direct care initiatives and business operations are critical success factors. Analytics and integrated technology have made significant advancements addressing critical management oversight and administration pain points in the move to Value-Based Care. The reality is that value-based care requires a robust technology platform to integrate within the analytics, care management, and administrative processes. Many providers have been leveraging three to five-point solutions, with different data definitions across persistently siloed systems and processes. The end product has been disconnected data requiring manual interpretation.
Today’s new and advanced integrated platforms homogenize data and create accessibility at the patient level to close risk-equation gaps. Providers benefit from more concise insights enabling more precision in patient care. Further, through integrated platforms, the administration of claims is streamlined with a capitation engine that processes the complexities of payment.
Centers of Excellence and PCP’s
Within value-based care models there are PCPs who provide services as part of Centers of Excellence (COE), which comprises a team of doctors who strive to keep patients out of hospitals and avoid chronic and life-threatening illnesses. COEs create the ultimate partnerships upon which Self-Funded Employers, Payers, Delivery Organizations, PCPs and Specialists truly collaborate to improve quality, costs and patient outcomes. For example, through COEs, PCPs have a robust list of qualified specialists to whom they refer patients for advancing and procedural next steps in their healthcare journey. Additionally, COEs offer predictable pricing and the opportunity for PCPs to help prevent risky and costly health conditions through early detection and interventions. Physicians are incentivized to provide the highest quality of care, while preventing expensive and life-threatening health conditions. COEs, like Capitation Models, require sophisticated technology, analytics and administration expertise to ensure success for all engaged participants.
With the combination of advanced, integrated analytic platforms, proactive care management, and coordination through the COE model, organizations can secure financial stability and lower risk, while delivering patients with proactive, preventive care for a new standard in outcomes.
1. Czeisler MÉ, et al. “Delay or Avoidance of Medical Care Because of COVID-19-Related Concerns – United States, June 2020.” MMWR. Morbidity and mortality weekly report vol. 69,36 1250-1257. 11 Sep. 2020, doi:10.15585/mmwr.mm6936a4.