How Can Health Care Purchasers, Providers Better Coordinate to Improve Value-Based Care Delivery?

The COVID-19 pandemic spotlighted the lack of preparation and notable disruptions in the US health care delivery system. To optimally transition to delivering high quality and affordable care, findings from a report by the National Alliance of Healthcare Purchaser Coalitions and the Council for Accountable Physician Practices (CAPP) suggest that enhanced care coordination, greater investment in delivery systems and primary care, and aligning reimbursement with patient outcomes is warranted, said Norman Chenven, MD, vice chairman of CAPP.

The COVID-19 pandemic spotlighted the lack of preparation and notable disruptions in the US health care delivery system. To optimally transition to delivering high quality and affordable care, findings from a report by the National Alliance of Healthcare Purchaser Coalitions and the Council for Accountable Physician Practices (CAPP) suggest that enhanced care coordination, greater investment in delivery systems and primary care, and aligning reimbursement with patient outcomes is warranted, said Norman Chenven, MD, vice chairman of CAPP.


AJMC®: Hello, I'm Matthew Gavidia. Today on the MJH Life Sciences’ Medical World News, The American Journal of Managed Care® is pleased to welcome Dr Norman Chenven, vice chairman of the Council of Accountable Physician Practices, or CAPP. Can you just introduce yourself and tell us a little bit about your work?

Chenven: Sure. I'm Norman Chenven, and I'm a family practitioner by training. I founded Austin Regional Clinic, which is currently the largest outpatient delivery system in Austin, Texas with 340 physicians and 28 locations. I've been a member of CAPP for its entire duration, which is approximately 15 years. CAPP, or Council of Accountable Physician Practices, promotes the organized delivery of care through physician led medical groups, whether they're in conjunction with a larger system or standalone. Austin Regional Clinic happens to be a stand-alone, physician-owned, physician-governed group but many of the CAPP groups are your large name brand groups such as Kaiser Permanente, Mayo, Cleveland, etc.

AJMC®: Amid the COVID-19 pandemic, can you give insight onto the current state of the US health care delivery system?

Chenven: So, with the onset of COVID, it reminds me of what Warren Buffett once said, which was that when the tide goes out, you find out who's not wearing a bathing suit. With COVID, the tide has gone out and it has shown a lot of disruption in the delivery system. It’s shown that we haven't been prepared. It has put a lot of financial stress, as well as just care delivery stress on the system.

I think that groups like CAPP groups, larger groups that have infrastructure and professional management and have planning capability into the future have fared better than smaller groups that are pretty much reliant on their day to day cash flow; but, all in all, the American health care system has not acquitted itself terribly well. Though, there's been a lot of creativity and response and I think at this point, we have all segments of the system doing their best to get back in the game. Telemedicine has been a lifesaver. Most of the CAPP groups have been engaged in telemedicine for many years, but even for us, it's been something of a revelation of how well accepted telemedicine has been when it was the only alternative.

AJMC®:What are some of the factors that warrant consideration among employers and health care purchasers when it comes to developing health care plans? And what are some common mistakes?

Chenven: So, I wouldn't say they're common mistakes. I would say that the system is afflicted by 2 factors–1, it’s very, very fragmented. So, pieces of care are delivered by different entities that are not necessarily aligned with each other, or even in communication with each other, and the business model is a fee-for-service business model, which means you only get paid if you do something to a patient, as opposed to really the alignment would come in being paid for keeping people healthy and well–that's the reward. That's the goal we should want.

We shouldn't want people to be sick so we can do something and get payment. What that does, it means that there's no upfront ability to invest in keeping people well. Now, groups like CAPP groups do have contracts with health plans, and with employers, where we do have upfront financing that allows us to build an infrastructure to help our patients take care of themselves and do outreach to monitor quality, to connect the system together, and electronic medical records have been a boon. They've been expensive and complicated, but again, larger entities have been able to connect with other entities and provide more integration in the care delivery.

AJMC®: In the new report by the National Alliance and CAPP, “Exploring Employer-Physician Collaborations to Deliver Quality Care,” the volatility of the US health care delivery system was a major takeaway. Can you further discuss report findings and what employers and health care purchasers are seeking based on the current market?

Chenven: Yeah, so this initiative and this report is about communication from providers of care directly to employers who are purchasing care on behalf of their employees, so self insured

health plans. The goal was to open up a line of communication and as strange as it may seem, there historically has not been good communication between the purchasers and the providers because there's so many middlemen. Middlemen being health plans in particular, but also brokers and consultants.

I think it's a lot easier to solve a problem if you're talking to somebody directly. Rather than play a game of telephone–I tell the health plan, the health plan tells the broker, the broker tells the employer, and then the message comes back the other way. We're trying to shorten that chain and understand better what employers want, what they need, how they'd like to fix things, and again, I don't think I would call it volatility. I would just say that health plans and the way the health delivery system is designed is not delivering an acceptable product or service to the employers, their dependents, and employees.

AJMC®: How can employers and health care purchasers optimally transition to delivering high quality and affordable care?

Chenven: So, if you read the report, you find that the problems that people have been aware of and in particular the large employers and medium sized employers, there's just a lack of coordination. As I mentioned before, fragmentation is a big issue. So, the more you can coordinate the care around the patient, the better the experiences for the patient, the more likely you're going to get a good outcome.

So, again, investing in delivery systems so that we can make those connections and make them smooth and capable, makes a big difference. In addition, there's clearly been inadequate access to behavioral health, and there's been an inadequate sighting of behavioral health services within the primary care delivery system. So, there's just disconnect, and that's fragmentation yet again.

If it is possible to bring behavioral health into the exam room, and it is, particularly now with telemedicine, we can improve the patient experience and really avoid some of the failures in delivery. A third issue has been just literally under investment in primary care. There have been many, many studies across the years, that show that patients who use primary care as their front door to health care, do better, have less expenses, have better outcomes, and are more satisfied with the care they get, but as we all know, primary care is poorly reimbursed.

The United States, again, part of the fragmentation, and then also the way health care is delivered has developed over the years. Specialists get paid enormous sums of money, primary care, scrapes by–that's okay, I'm a family practitioner, I'm not complaining, but there's been underinvestment in organizing primary care and making sure primary care can act as a real facilitator for patients care.

Employers really have spoken out in these meetings about the lack of transparency of how healthcare is paid for, they don't understand the billing mechanisms, and that's not surprising because they're very complex and elaborate. I have to have an enormous staff just to bill and collect for my services. So, I can go down to Home Depot and buy a lawn mower. That's very simple. I understand what I'm getting, I understand where the money went. In health care, if you're going to have an appendectomy, you're not quite sure how much your health plans are going to pay for it, you're going to get bills from 4 or 5 different entities–the anesthesiologist, the laboratory, the hospital, the primary care doctor, the surgeon, it's crazy. It's a system that needs to somehow be wrapped together and made more transparent so people know what's going on.

Then, lastly, again, I've already mentioned this, that the way that reimbursement is structured, does not encourage, incentivize, or reward physicians for continuity of care for their patient. That has been changing over the years, but not quite enough. Medicare Advantage is a shining example of change in the way health care is reimbursed, where the delivery system is reimbursed for good outcomes, for measured quality, for patient satisfaction, and access.

So, I would say that if you think about what you really want out of health care–you want patient satisfaction–a satisfied customer, you want access–so, when somebody's sick, they can get the care they need, and that's also a problem because of fragmentation. You want there to be quality and you want that quality measured. In health care it's difficult to know who's providing the best quality, who's doing the best surgery, who's managing diabetes better than someone else, because that has downstream consequences. Lastly, what's the overall cost, not the cost for a unit price, which is what we have in fee-for-service. So, an office visit is x number of dollars, a surgery is y number of dollars. That really doesn't matter to the person who's ultimately paying the bill because it's what the total cost of care was. In an unmanaged and a not chaotic, but not organized system, the costs go up and the quality goes down.

AJMC®: To build on top of that, what are the next steps to further delineate what needs to be changed or altered in the current US health care delivery system?

Chenven: So, I have my own personal views. I think we're in the midst of this process, and I think more discussion between our groups, the CAPP groups, and the National Alliance groups of health care purchasing organizations, coalitions–I think we have to understand each other better. What was very clear, if you read through some of the deliberations and discussions was that for the most part, employers did not understand how the system worked. They didn't understand where the incentives were. They felt overwhelmed. They had been relying on outside experts or intermediaries to explain the system to them, and that that has not worked well.

Again, I think it's a game of telephone. The message changes as you pass it on from 1 to the next, as opposed to being a direct message. So, I think the goal right now is really to see us continue this discussion and start to work out solutions a little bit at a time. This is a huge complex system. Our group alone has 50 different payers that we contract with. If you step back and look at the system as it is, there are all kinds of tranches. So, you have Medicare patients, Medicaid patients–I spent 2 years on the Navajo Reservation in the Indian Health Service, then you have the military, and the VA [Veteran’s Association] is not the same as the military. It just goes on and on.

In our city, we have a substantial population with no coverage whatsoever. So, there's a safety net system that Travis County provides. It's very hard to organize yourself around such a system, or it's actually a non-system, an anti-system. So, I think there's just got to be more exploration and then experiments.

Experiments like can we change the payment model and develop incentives and rewards for the system responding to the change payment model, and bring in behavioral health, which is poorly reimbursed at this point, and maybe give more assets and infrastructure to primary care so we're much better able to take care of our patients and be aware of what their needs are.

AJMC®: Lastly, are there any other concluding thoughts that you may have that have not yet been addressed?

Chenven: I appreciate the opportunity to raise this issue on a larger stage. I think there's a lot of work yet to be done. Again, COVID is really a side issue in many ways, but it was the tide going out and we're all standing around with our bathing suits around your ankles. We need to fix all of that and really prepare ourselves for the next pandemic, which there surely will be 1, and we need to organize the way we deliver care better.

AJMC®: To learn more, visit our website at I’m Matthew Gavidia, thanks for joining us!

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