Implications of Value-Based Care, Fee-for-Service Reimbursement Models Amid COVID-19

Amid the pandemic, organizations utilizing a value-based care reimbursement model may be better positioned than those using a fee-for-service model to delineate high-risk patients and manage their care, particularly for long-term symptoms that may arise due to COVID-19.

Amid the pandemic, organizations utilizing a value-based care reimbursement model may be better positioned than those using a fee-for-service (FFS) model to delineate high-risk patients and manage their care, particularly for long-term symptoms that may arise due to COVID-19, said Kevin Coloton, MBA, MPT, founder and chief executive officer of Curation Health.

Transcript

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 Kevin Coloton, founder and CEO of Curation Health.

Great to have you on, Kevin, can you just introduce yourself and tell us a little bit about your work?

Coloton: Absolutely, thank you Matt. I’m Kevin Coloton, founder and CEO of Curation Health. We’re a clinical decision support platform dedicated to value-based care, and I'm based in Annapolis, Maryland.

AJMC®: To get us started, can you speak on the implications of a value-based care reimbursement model vs a FFS model amid the pandemic? How have organizations utilizing each model fared?

Coloton: It’s a big question, one that a lot of people are paying very close attention to right now. I think it’s important when we're talking about these 2 models, and the compare and contrast, is to really explore the fundamentals of each quickly and then talk about the exact implications of it.

So, fundamentally, value-based care ties a component of the reimbursement to the measure of total value. So, performance on those measures tends to be the critical focal point for an organization. FFS models tie reimbursement to the build codes. So, therefore the volume of services delivered is the utmost importance and the highest priority and therefore the focal point of that organization.

Not always that simplistic, but in essence, it often is, and hence the reason people when they're moving from FFS to value-based care, they describe this shift from volume to value. Those fundamentals of those 2 programs have not changed during the pandemic, and candidly, the payment structures haven't changed either during the pandemic, but what has changed is the care needs of the community.

Based on the incentives of those 2 models, we might expect to see them perform a little differently on measures such as community health, for example, both now and during COVID-19, and likely in the future as well. So, specifically around value-based care, value-based care, traditionally and currently, incentivizes a focus on care management and the infrastructure required to deliver preventative care, which is a little different than the FFS model.

In the near term, we're seeing the management of high-risk patients to be a real priority during the COVID-19 pandemic. The elderly, people with pulmonary issues, and patients with heart disease, for example, are particularly at risk with COVID-19.

Theoretically, those patients will be better protected from COVID-19 and more aggressively treated if they receive a COVID-19 diagnosis if they're part of a value-based program, likely because those providers are already closely monitoring the health conditions of those patients and already regularly communicating and engaging those patients and encouraging their patients to participate directly in their health, in their holistic health. In addition, they're wired pretty well with community services and support structures within a region or geographic area.

When we look at value-based care as it pertains to COVID-19 and the future, we're seeing a lot of sequela from COVID-19, essentially long-term symptoms from having had COVID-19 are existing for patients, and there's a lot of considerations of how those contribute to other chronic diseases or if some of these issues become long-term health challenges and need to be managed carefully. The value-based care model, in theory, likely positions those patients to be better positioned to manage those symptoms over the long-term.

We'll see how this plays out. I haven't seen the numbers yet, and I think it's easy to forget that value-based care is very nascent in most organizations and the question is how much of this infrastructure was already built prepandemic. As you're likely aware, many of the organizations participating in value-based programs are relatively new to these programs and often haven't had downside risk, at least not since the 1990s. And a lot of these organizations had not reached a state of value-based care infrastructure maturity as they approached the COVID-19 onset in early 2020.

So, when COVID-19 hit it impacted providers in extreme ways, and a lot of visits just stopped happening. And it was true that FFS providers and value-based care providers were impacted significantly.

AJMC®: You touched upon the pandemic affecting providers who already are in this value-based care model infrastructure. Can you expand on how the pandemic has affected efforts from payers and providers in transitioning to a value-based care model?

Coloton: Yeah, absolutely. Those in organizations in the process of transitioning froze their spending appropriately, because we really didn't know what we were up against, and that had a negative impact on the infrastructure development that many of these organizations were embarking on. It also meant a lot of the value-based care contracts that were being negotiated, researched, and analyzed were put on hold. I do think they're warming up now, but for those that kept forging ahead, and already had some form of infrastructure in place, I think the pandemic has encouraged more aggressive data sharing for population health management purposes, which is excellent.

It's sharing from payer to provider, from provider to payer, and even some sharing of resources for things such as chart reviews and better understanding the comorbidities that patients are challenged by and other related activities—helping focus the the limited attention that organizations have on the highest-risk population that they are caring for as an organization and the conditions that they have to manage to deliver care.

So, again, in summary, initially, I think it was a full stop, a bit of a freeze, and then a thawing out period of time as they received better understanding of the implications and that they just needed to continue. The show must go on and I think organizations are starting to gain momentum again in those strategies.

AJMC®: Looking to the year ahead, how can payers and providers optimally implement a value-based care system and what unmet needs warrant consideration?

Coloton: Yeah, great question, Matt. I think the key is going to be to continue the work underway, gain more momentum. There's still quite a bit of inertia. There's a lot of unknowns today, patients are still scared to go to clinics, they're still scared to leave their homes in some cases. So, it's overcoming that inertia by continuing to build out your organization's preparations.

A few of the examples would be continuing to work on data sharing, it's critical at any time and there's a lot of work to be done on better sharing data and actually getting better data, having clean data that's usable and able to facilitate the care delivery workflow. I think the models of risk sharing are in need of continued exploration. I think there's a lot of flavors, and I think there's a lot of room to experiment and improve for organizations that commit to arrangements that can be studied and evolved. I think iteration and optimization is going to be an important part of getting these models to be dialed in—to be sustainable, one, to engage the providers in the journey and get them more directly involved, as well as get the patients involved in value-based care strategies.

Then I think it's important also to remember that, despite COVID-19, the show must go on, and a continued effort is needed to invest in the development of value-based care platforms because the goals remain the same. We need to be focused on creating systems of long-term sustainable care for organizations. And I think that's going to ultimately be the key driver—that COVID-19 has essentially become the ultimate wargame scenario for why value-based care is (1) important, and (2) how it can be applied to something as devastating as the COVID-19 pandemic.

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