High Value Specialty Networks in VBC
by Andrea Hurteau, Winston Healthcare Advisors LLC.
As a follow-up to the VBC Drivers article on Preferred Provider Networks, this article will focus on the importance of at-risk Primary Care Physicians engaging Specialty Physicians in driving Value-Based Care (VBC) outcomes through the development of High Value Networks (HVN) for continued performance improvement in VBC models.
VBC is a collaborative effort that takes engagement and alignment across many key stakeholders, primarily the Patient, Payor, Primary Care Physician (PCP) and Specialty Physician (Specialist). The critical role that Specialists play in overall VBC success cannot be understated. The majority of downstream medical costs for patients in the PCP’s VBC patient panel (Panel) are driven by Specialty care. These are costs that ultimately the PCP is accountable for in most VBC contracting models.
Specialists order diagnostics, prescribe Part B drugs, determine the site of service for procedures, admit patients, and influence discharge disposition for post-acute care. In addition, they aid in the management of chronic conditions that can drive much of the overall utilization. Therefore, meaningful variances exist among Specialists related to their overall “efficiency” and value contribution due to quality and cost outcome differences.
Highly efficient and effective Specialists are essential partners in VBC models especially when their healthcare reimbursement is generally on a fee-for-service basis (even under VBC contracting arrangements) and therefore financially incentivizing the provision of more services to be provided, not financially motivating based on quality and cost outcomes.
This misalignment of incentives is one of the greatest challenges in the delivery of VBC and why the outcomes often fall short despite the efforts of the PCPs.
Since the majority of healthcare costs are managed by Specialists, an advanced stage in VBC model progression must include a more purposeful value-based alignment between the PCPs and Specialists. This can be challenging to achieve. In fact, CMS’s innovation center (CMMI) has a comprehensive specialty strategy across several new test models to focus on the integration of specialty care into VBC models.
PCPs need to have an intentional strategy to more closely integrate Specialists into VBC models of care beginning with the creation of a High Value Network (HVN) of aligned Specialists. While this may feel like an overwhelming task, an HVN can initially be limited to a few critical specialties that focus on one of the largest opportunities in VBC performance management, the management of Chronic Disease.
90% of the nation’s annual healthcare expenditures are for people with chronic and mental health conditions. Focusing on a core group of Specialties that manage chronic disease such as Cardiology, Pulmonology, and Endocrinology is a good place to start. Mental Health management is essential and highly impactful on overall health outcomes but can be challenging to effectively implement into current VBC models.
High-cost chronic diseases such as Cancer and Chronic Kidney Disease have their own dedicated value-based contracting models and often run in parallel and sometimes are mutually exclusive to Primary Care VBC models because of patient attribution methodologies. For this reason, they will be excluded from this discussion. In fact, their nuances warrant a separate dedicated follow up article.
The primary benefit of the HVN is to provide a patient-centric experience where care feels integrated and seamless to the patient instead of fragmented and uncoordinated, which is often the case in a fee-for-service model. The HVN performance outcomes are aligned with the underlying VBC arrangement focused on improving quality and overall total cost of care.
When developing a HVN, PCPs should choose their partners wisely. There are certain features that PCPs should look for in their VBC Specialty partners such as:
Patient Panel Volume: Large number of shared patients - either your practice or your patients are already using these physicians.
Patient Access: Reasonable patient access availability including accommodation of urgent PCP referrals
Patient Experience: Positive feedback from shared patients
Care Coordination: Strong bi-directional communication and record sharing
Quality & Cost Outcomes: Efficient care delivery
Efficient care delivery needs to be an expectation of the partnership and requires Specialist involvement that leads to value driven efficiencies such as avoiding test redundancy, closing relevant outstanding care and HCC gaps at the point of care, following evidence-based care pathways, and considering lower cost sites of service for necessary diagnostics and procedures.
The Specialist needs to be aligned and incentivized to deliver in this type of highly coordinated collaborative model of care. This level of Specialty engagement is game changing and can add significant incremental value to the partnership.
One of the benefits of VBC Payor arrangements is the comprehensive data and reporting that many payors share with the PCPs about their panel performance including overall quality and total cost of care. Payor claims data is the “source of truth” for any VBC program and can provide the PCP with a wealth of information about the downstream services their Panel receives throughout the continuum of care.
This data can also be leveraged to assist with HVN development by identifying variances in Specialist efficiency in managing episodes of care. Payors can be a helpful resource for this since they often perform Provider Network analytics and can share insights with PCPs on their downstream network performance and Specialist efficiency.
Engagement of the Specialist requires the PCP to approach the HVN collaboration with a Payor mindset. The larger the patient population that the PCP manages, the more interest a specialist may have in a HVN collaboration opportunity due to the size of the shared patient panel.
The nature of shared performance in managing a Panel requires the Specialist to be included in the overlaying VBC accountable care arrangement. Discussions must be data driven, transparent and highly collaborative. This is about building a partnership.
The Specialist VBC value proposition needs to evolve to include an opportunity for the Specialist to earn and share in VBC incentive payments.
Pay for Performance (P4P) incentives that reward VBC-related activities are the simplest incentive structure to both measure and administer. In P4P incentive models, the performance metrics for Specialists should be focused on a few activities that can be clearly measured and have direct correlation to overall VBC performance. Examples of activities include access availability (appointment within x days of referral), specialty/disease-specific HCC and care gap closure, site of service optimization for diagnostics ordered and procedures performed etc.
More advanced HVN incentive structures involve shared savings and require secondary-level patient attribution to the Specialist panel. In this case the Specialist’s accountability broadens to include total patient downstream cost and quality. The Specialist would assume performance risk and reward in a similar manner to the PCP. Examples of determining attribution are one based on to whom the PCP’s referral was written or on the Specialist with the plurality of specialty services based on claims.
There are also non-financial benefits of HVN participation that can be included as part of the overall proposition. VBC partnerships that share some of the administrative burden, assist with value-based activities and provide access to population health management tools and resources could be part of the HVN value proposition.
Addressing administrative burden and speeding the sharing of clinical data turbocharge the HVN relationship, improving the experience of the Specialist's practice as well as the patient. Active, efficient, and effective communication between the PCP office and that of the Specialist are foundational to a solid HVN.
Greater collaboration results in faster, better quality Specialty referrals, and improved patient experience ratings that benefit all.
Frequent and effective communication and data sharing is key to a sustainable physician engagement and favorable VBC outcomes.
A core principle of VBC is the ability to more effectively coordinate care. Frequent bi-directional communication by the PCP and Specialist regarding their joint patient panel facilitates earlier patient intervention, improving patient engagement and encouraging collaborative patient-centric decision making. It also helps efficiently close the loop on referrals, allowing for timely patient outreach or additional follow-up as needed.
Bi-directional clinical data sharing is necessary for VBC quality programs, and data sharing between the Payor, PCP and Specialist is critical for continued performance improvement. This is a necessary component of a well-functioning HVN.
The amount of data available can be overwhelming and it’s difficult to not get caught up in the weeds. Sharing clinical data is often tedious and inefficient due to lack of integrated electronic medical records. A Population Health Management tool can be an effective bi-directional communication avenue and allows for a patient-centric approach to data collection across multiple providers. This can add incremental value and should be worth evaluating as VBC programs scale.
When sharing performance and clinical data with downstream Specialist partners, it is imperative to identify and focus on actionable insights that the Specialist can meaningfully execute on. This ability to focus on a few highly impactful actions can really move the needle on collaborative VBC performance that benefits all partners in the HVN.
As with everything in healthcare, there are always nuances. It is important to ensure all components of the HVN partnership are operationally, financially and compliantly feasible. More advanced HVNs may require a formalized operating structure including downstream Participating Provider contracts. It’s important in these cases to involve legal and other expert guidance. Building and engaging an effective HVN is a critical next step for an evolving PCP VBC practice and can provide an opportunity for improved PCP and Specialist alignment and better outcomes.
