In a presentation at the National Association of Managed Care Physicians (NAMCP) Spring Managed Care Forum 2023, Robert L. Waterhouse Jr, MD, MBA, HSM, chief medical officer at Baylor Scott & White Quality Alliance, discussed the challenges of value-based care implementation and how to overcome them.
Succeeding under value-based care contracts is a multifaceted endeavor that demands attention to a host of moving parts within a health care system. From care team collaboration to the implementation of new tools and processes, a significant amount of work goes into addressing the challenges of value-based care implementation.
In a presentation at the National Association of Managed Care Physicians (NAMCP) Spring Managed Care Forum 2023, Robert L. Waterhouse Jr, MD, MBA, HSM, chief medical officer at Baylor Scott & White Quality Alliance (BSWQA), shared his experience implementing value-based care in an extensive health system. BSWQA is a non-profit, mission-driven accountable care organization (ACO) that includes physicians, hospitals, care facilities, and other health care stakeholders “all agreeing to be jointly accountable for improving quality, enhancing the patient experience and reducing healthcare costs.”
The Texas-based ACO encompasses more than 1000 providers both employed and affiliated at over 700 facilities, and more than 40 hospitals. Altogether, more than 900,000 patients are covered at BSWQA, which operates in 29 counties In Texas. It was the top performer in the United States in terms of generating shared savings in 2021, with $124.5 million in Medicare Shared Savings Program savings.
Overall, BSWQA identified 6 areas in its own journey that could pose challenges to performing well in value-based care contracts for any practice, Waterhouse said:
Waterhouse noted 4 key areas where diligent senior leadership has been crucial to managing these challenges. This includes someone accountable for having a high-performing primary care network, a leader for comprehensive care management, someone accountable for data reporting and analytics, and business development and the physician network.
He began with a deeper dive into the first intervention, which was creating a multidisciplinary care team and clinical strategy through evidence-based guidelines to reduce clinical variation.
“It's important to be able to have a collaborative interdepartmental clinical strategy, and that part of that clinical strategy be devoted to reducing clinical variation,” Waterhouse said. “As with any business, undesirable variation is costly—it's no different in health care. Collaboration across departments, breaking down silos, ultimately leads to better outcomes and better results.”
The improvements seen—better multidisciplinary collaboration and a decrease in clinical variation—come from improved consistency with following evidence-based guidelines to improve care.
Another issue that often flies under the radar was providers’ inability to identify BSWQA patients or ensure that these patients stayed in network, Waterhouse said.
“The same way that they didn't know that it was a problem, they didn't know what process [they should] be following to make sure that we're actually referring patients in network,” Waterhouse said. “So, a lot of things have to be created to improve that process.”
Network utilization was added to a provider dashboard that allowed them to see what their success rates were. And following this intervention, in-network care utilization increased.
Overall, Waterhouse emphasized the importance of provider dashboards to drive success in ACOs. While management teams typically have a comprehensive view and understanding of metrics, an easy-to-use dashboard for providers loops them in and allows them to see where there is room for improvement in the most common value-based care metrics across multiple payer contracts.
The third focus area was implementation of a performance program to hold providers accountable.
“A couple of things of note here, and that is you not only need to be able to measure individual provider accountability, but you also need to be able to individually impact what that single provider is doing,” Waterhouse said. “And you need to be able to do that at multiple levels… But you have to measure performance, and you have to report on performance if you want performance.”
For BSWQA, performance was lagging as providers did not know where to focus their efforts due to multiple contract measures. A “Value-based Care Star” measurement was developed to measure goals and develop thresholds based on the most common payer measures, as well as provide an action plan for improvement.
This strategy, which includes a composite measure of value-based care goals, led to both financial improvements as well as improved care. Implementation of monthly data reviews, dedicated physician support teams, and quarterly outreach to providers and practices supported improvement for physicians. Education in this realm is also important, as physicians need to know what metrics contribute to this rating.
“What we have found, in addition to that impact on quality and non-financial performance, [is that] this actually aligns with delivering good care, it actually aligns with good outcomes, it actually correlates with getting more preventative measures done, it actually correlates with better management, chronic conditions,” Waterhouse said.
For the fourth intervention, accountability processes for quarterly quality and utilization measures were created based on minimal acceptable standards. This means having a parallel track to a rating such as the Value-based Care Star system that addresses gaps in care from a management perspective.
“In this fourth area, [there are] new processes to address internal gaps in care. It's nice to measure, nice to monitor, nice to inform, and nice to educate. But if you don't, in parallel, have some things that are happening outside the provider to actually address internal gaps in care, you can still fail,” Waterhouse said.
He stressed the importance of identifying patients with gaps in care, but also the importance of avoiding duplicating efforts. Various reports were used with different dates, definitions of measures, and sources to identify gaps, and the analytics team at BSWQA developed a standardized report based on payer gap reports to improve efficiency and minimize duplication.
A specific example was the Chronic Care Management team, which decreased effort duplication notably and reduced the number of patients needing care gap closure outreach.
The sixth key intervention addressed the issue of patients having multiple care gaps and providers having limited access to patient-level data. This is another area where provider dashboards were useful. Dashboards were updated to include the Value-based Care Star reports, including provider performance and patient-level data for each measure and links to resources for performance improvement.
“At the onset of this, in the initial iteration, the provider dashboard just looked at their overall performance but didn't give them any information about individual patient gaps [or] individual patient performance,” Waterhouse said. “And so, these needed to be updated. This was an enhancement that required additional analytics and additional technology, but it is very valuable because oftentimes, what a provider can’t see is there's really a handful of patients that are creating a lot of gaps.”
While the interventions Waterhouse detailed take work to develop and implement, the results have paid off for BSWQA from both a financial and patient experience perspective, he noted.
Compared with 2021, 2022 saw more patients with blood pressure in control, more children and adolescents completing wellness visits, more patients receiving kidney health evaluations, and fewer unnecessary antibiotic prescriptions. And on the cost savings side, increases were seen in gross contract savings, employer savings, and performance revenue, with only minimal increases in the cost of interventions.
“You have to understand the resources available and be judicious with how you utilize them,” Waterhouse concluded. “You have to be intentional with managing the patient as well. And that's done by informing providers, decreasing clinical variation, having a structure for clinical pathway development, evolution, maintenance, education, and reiteration. And you have to make sure that, as incentives are aligned with objectives, you need to incentivize the behaviors that you're trying to drive.”