It’s time to start a new chapter in value-based care.
As a former health plan executive, I spent years on value-based care initiatives aimed at improving quality and lowering cost of care. Because it was measurable with claims data and influenceable with physician incentives, my work was focused largely on what needs to happen inside the doctor’s office and in the hospital.For many health insurers, top clinical priorities are things like closed care gaps, improved HEDIS measures, completed annual wellness visits, avoided emergency room visits, and reduced inpatient admissions. Payers invest in administering physician incentives and risk contracts that promise to deliver on these metrics. Delivery systems and physician practices respond with integrated care models that support the highest risk segments of the population.
Yet after decades of evolving physician incentives and care models for value-based care, we still face growing prevalence of chronic disease, unprecedented levels of mental health challenges, and uncontrollable cost trends. We thought population health would change things, but it’s clearly not enough.
Like never before, we now have the digital tools to change the paradigm. “Good health,” along with the tools and interventions that support it, need to be a part of day-to-day life of all consumers. With digital tools, we can expand far beyond the 5% of the population that drives 50% of the cost and the activities conducted at traditional sites of care. If we embrace it in value-based reimbursement models, digital health can lay an exciting framework for a new chapter in value-based care, one that focuses much more strongly on day-to-day care outside the doctor’s office and outside the hospital.
What’s been missing from value-based care?
After seeing some of my own family members face some serious mental health and chronic disease challenges, I’ve had to ask myself why I wasn’t seeing the impact of my career in value-based care show up for my family in their time of need. They did their annual wellness visits, stayed out of the emergency room, and closed their care gaps but this didn’t prevent my family’s health crisis. We likely didn’t appear on any hotspotter algorithm or predictive trigger. Having said that, my family’s physical and mental health started to deteriorate long before the crisis, but we didn’t take the time or have the tools to address it. Like my family, the majority of the population suffers unmet health needs in their day-to-day lives, unbeknownst to most predictive models. They need support that goes deep and empowers them to take charge of their health. They need coaching on what healthy eating looks like, personalized by South American or Asian or whichever cuisine they follow. They could learn what impact carbohydrates have on energy, what side effects to expect from medications, how to deal with intense stress, how to rebuild energy after chemotherapy or surgery, how to ensure adequate high-quality sleep, and how to get back on track when falling out of a healthy way of life. They need to know their options when they can’t afford medications or don’t have easy access to healthy foods.
We can’t really deliver support that “sticks” on these types of complex issues if we limit our care models to one or two annual encounters with our general practitioner. We need continuous care models that fit within the context of each person’s daily life, culture, and economic circumstances. The pandemic taught us exactly how important it is to offer safe, continuous access to care between physician visits. As an industry, we scratched the surface on this aspect of care through telephonic disease management and team-based integrated care. The truth is, value-based care has been missing the tools needed to deliver day-to-day support on health.
What gaps can digital platforms address?
I’ve heard the cynicism and asked the questions myself. Do health apps really work? Do consumers actually engage in them and achieve meaningful outcomes?
If Covid-19 taught us anything, the answer is yes. I’ve had the opportunity to study consumer engagement data in digital health and the insights are clear. The data confirms that health is most certainly human first. Using motivational interviewing, health coaches and dietitians can build strong bonds virtually. Once they form a strong human connection, consumers engage for a long time across multiple modalities, relying less and less on human support throughout their journey.
For example, imagine a digital platform where a 55-year-old Latino woman with diabetes and depression starts with a few 1:1 synchronous video sessions with a Spanish-speaking dietitian. As she gains trust with her dietitian, she opens up to the suggestion of seeing a therapist in tandem. The therapist and dietitian work together virtually on her care plan, and these human relationships spark the first steps of her health journey. Her care team elicits the needed self-motivation, and her engagement goes way beyond her sessions. For months she sends chat messages, completes curated video health lessons, tracks hundreds of biometrics through connected devices, and participates in Spanish social chat group on carbohydrates. Within 3 months, she lowers her A1C by 1.5 points, loses 10 pounds, and reduces depression 40% based on her PHQ (Patient Health Questionnaire for depression).
This is not a hypothetical example of a possible future as these digital platforms are already being used today. However, most disease management programs would have “counted” her initial telephonic sessions but missed the value of continuous digital engagement. Winning digital health platforms will get this right — they are both human and digital at the same time.
We can also hold a much higher bar on digital platforms to avoid the fragmentation we have created in today’s system. People have depression, hypertension, diabetes, stress, and sleep health issues all at the same time. People need wellness, mental health, and chronic condition management simultaneously. We should not have to send them in 10 directions. Many advanced primary care models with multidisciplinary care teams recognized this. With digital, we can do multidisciplinary, integrated care, virtually. We can make sure that we offer up appropriate personalized pathways for members that cannot afford medications, need culturally appropriate diet plans, or have mental health challenges to address before they can make progress physically. In short, digital platforms can take us to the next level of scale and personalization. We shouldn’t settle for fragmented point solutions.
Who controls the platform?
Is it the payer or the provider that owns the digital platform? The industry is exploding with digital solutions, all with transformational promise. The platforms that win are the ones that consumers use. Consumerism is simple that way. It’s easy to get lost in all the complexity of interoperability and combining sources of data from electronic medical records to claims to social determinants.
At the end of the day, consumers are the source of truth on health and we have to earn the privilege of stewarding their information and supporting their health. We have to convince them that any digital platform we offer will genuinely serve and support their health needs. We need to win their confidence that we are worthy stewards of their personal health data, and we need to empower consumers to own their own health information.
If we could learn anything from Amazon or Netflix about doing business with consumers, it’s that you have to focus on consumer engagement like your life depends on it. It’s a do or die mindset. If consumers engage, you’re in business. If they don’t, you’re out. I deeply appreciate the complexity of “build vs buy” decisions inside large healthcare organizations, but will payers or delivery systems be able to adapt the mindset needed for consumer engagement? Or is it time to make room in value-based contracts for new entrants whose entire purpose is to drive day-to-day consumer engagement that correlates to health outcomes?
How can we shape the next chapter in value-based care?
The long-standing goal of value-based care has been the Triple Aim: improve the health of populations, lower per capita costs, and improve the patient experience. As a result of investment in value-based initiatives, we have seen some positive signals on cost reduction and quality in select populations in some disease categories and in some parts of the country, but we’re far from universal progress on the triple aim. As CMS Administrator Seema Verma put it, “the return on investment has been poor.”
The problem may be deeply rooted in the fact that the care models have not “reached” consumers meaningfully, particularly not on day-to-day health. It may take time to prove the trend savings and quality results from digital tools, but we can know quickly and with high certainty their impact on sustained engagement, where digital can be an X factor.
Whether shared savings, bundled payments, or full risk, consumer engagement should take center stage in value-based arrangements. The next chapter of value-based care should measure engagement like our lives depend on it. We should include the full scope of human and digital activity together, both synchronous and asynchronous. We should reimburse consumer digital health services and encourage physician referrals to drive adoption. We should unleash the power and convenience of digital tools to move the needle on value-based care.
Photo: Natali_Mis, Getty Images
