Championing Value-Based Primary Care: How Practices Can Support and Optimize Health Outcomes

Am J Accountable Care. 2023;11(2):39-41. https://doi.org/10.37765/ajac.2023.89384

Cost of care and waste remain significant barriers to primary care quality improvement locally and nationally, and building the infrastructure required to advance care delivery warrants evidence-based tools, data analytics, and technology, noted Ken Cohen, MD, executive director of translational research for OptumCare.

Cohen and Lee A. Norman, MD, MHS, MBA, senior medical director of Optum Kansas City, served as cochairs of an Institute for Value-Based Medicine event hosted by The American Journal of Managed Care® in Kansas City, Missouri, on March 9, 2023. The event was held in partnership with Optum.

Cohen served as chief medical officer of New West Physicians for 25 years; the practice was acquired by Optum in 2018. Part of the acquisition entailed bringing the Optimal Care Model employed at Cohen’s practice, which combines evidence-based medicine with data and technology, and scaling it nationally to all of Optum’s care practices, which collectively form the largest ambulatory system nationwide.

In aiming to transform primary care delivery on a national level, Cohen highlighted the overuse of low-value care as a major focus of the model.

“What a lot of folks don’t recognize is that a third of the care that’s delivered in the United States doesn’t improve health outcomes and doesn’t improve quality of care. So, at its best, it’s wasted care,” Cohen said to the audience. “If you take one point home today, it is that there is no relationship between cost of care and quality of care. And not only is more care not better care, but very often it actually turns out to be harmful care.”

Findings of a study examining health care waste in Washington state showed that nearly half of 1.3 million patients received care that is considered low value or wasteful, contributing to an estimated $282 million in unnecessary health care spending in 1 year in Washington.¹ Along with presenting a significant cost burden to health care systems, wasted care has the potential to cause physical, emotional, or financial harm to patients.

“[Waste] is either directly harmful or it leads to a diagnostic cascade that ultimately has the potential to wind up [causing] harm.… The Optimal Care Model begins with a physician culture that recognizes the magnitude of the problem and the dysfunction that’s inherent in our health care system and also recognizes that we [physicians] need to be the ones to correct it,” Cohen said.

With physician-led decision-making and evidence-based education at the forefront of innovation, the model leverages several strategies to support value-based care (VBC) delivery in primary care practices:

• Point-of-care algorithms
• Shared decision-making
• Referral and site-of-service optimization
• Patient-reported outcomes
• Artificial intelligence/machine learning predictive modeling
• VBC compensation models
• Development of a high-performance network that reduces inefficient and low-value care

In the real-world setting, Cohen discussed the application of the model to the management of chronic lower back pain, which accounts for $90 billion in US health care spending each year.²

The current standard of care for lower back pain—prescription drugs and surgery— contributes to significant waste and potential harm for patients, he noted. Although only 2 drug therapies have demonstrated proven benefit for chronic lower back pain (nonsteroidal anti-inflammatory drugs and the antidepressant duloxetine), patients are often prescribed drugs with no clinical benefit.

“Gabapentin use has increased 10-fold in the past decade—10% of overdose deaths now are related in part to gabapentin utilization, and no evidence supports any benefit in chronic lower back pain,” Cohen emphasized. “A lot of these drugs are in the high-risk Beers list, so you actually get dinged on your quality scores if you use those.”

The Optimal Care Model eschews these common care practices and instead opts for lower back pain to be coordinated through the primary care provider (PCP), a physical therapist, or chiropractic care. If back pain persists, care is then escalated to the 2 drug therapies with proven benefit, rehabilitative services, and cognitive behavioral therapy for pain management.

Most patients have reported improvements in pain with these modalities, Cohen said, but for those whose back pain still has not responded to treatment, surgery referrals are then the last step. However, surgery referrals happen only after engaging in shared decision-making with patients, because lumbar procedures are high in cost with a potentially short duration of clinical effectiveness: 25% chance of revision surgery within 2 to 4 years.

Cohen said that the model has based referrals on the results of a lumbar fusion calculator, which predicts the chance of a successful outcome by considering patient characteristics, potential benefits of surgical options (lumbar fusion or spinal decompression without fusion), the choice of surgeon, and where to have the surgery.

“As a PCP, you can look at so many things to evaluate the quality of the practice that you are providing, but how do you evaluate the quality of specialists? We’re honing down and actually developing specialty-specific metrics so that we can look at how specialists are managing their panel of patients and what the quality metrics are in any given specialty. Then we’ll create incentive pools to begin to move away from straight RVU [relative value unit] reimbursement,” he explained.

“An estimated 93% of the specialists in this country are paid exclusively on volume, and they’re paid whether that’s high-value care or low-value care—we pay equally. So, begin to change how you pay specialists so that there’s a balance of quality incentives around population health management at the level of that individual specialty and the volume component as well.”

Leading VBC Practices and Navigating Through Change

Speaking on the growing shift from fee-for-service (FFS) to VBC, event cochair Norman next addressed how primary care practices can thrive amid the uncertainty of transitioning to VBC and its associated operational risks.

Most Medicaid beneficiaries and all Medicare FFS beneficiaries will be in a care relationship with accountability for quality and total cost of care by 2030, noted Norman. Referencing an acronym used during his military service called VUCA, which stands for volatility, uncertainty, complexity, and ambiguity, Norman emphasized that although the dramatic changes coming to these programs may signal a growing VUCA environment in the health care industry, primary care practices can reap financial and quality-of-care improvements by taking the steps necessary to prepare for change.

“Many say they are worried about VBC when really what they’re worried about is change.… The forces out there will continue to change what we do and how we do it for a very long time,” Norman said. “FFS and VBC are not binary. There’s no boat, and there’s no dock. You’re not on an FFS base and then you jump over on the dock of VBC—I think it needs to be a bit more [of a] gradual transition than that. I think that the question isn’t ‘Am I going to be on the boat or on the dock?’ but ‘How can I straddle and how can I maximize what’s good for my patients, what’s good for the members, and what’s good for myself and my practice?’”

Key in the transition toward embracing change and achieving the Quadruple Aim—quality outcomes, patient satisfaction, lower costs, and provider satisfaction—is the importance of creating an environment that fosters growth among the care team of nurse practitioners, PCPs, office managers, and other health care staff so they can effectively lead VBC efforts in their respective departments.

Deliberate learning, education, and communication are topmost among these pursuits, Norman added. Prioritizing shared purposes and goals, transparency around performance, and early involvement of physicians and advanced practice clinicians will also be important.

“We can mentor other people around us so we can help them bring themselves along,” he noted.

As commercial risk and industry consolidation further fuel uncertainties regarding the evolving health care landscape, Norman said that engaging in these practice-level changes will be crucial to drive innovation and to advance quality of care and equitable health outcomes. He offered several strategies that can help practices avoid potential mistakes:

• Align practice goals
• Set the pace of change
• Rightsize your VBC practice
• Collect data
• Embrace treating different patients differently—match the right resources with the right patient regardless of the payment model

Getting Value-Based Payment Right for Primary Care

Karen S. Johnson, PhD, vice president of practice advancement for the American Academy of Family Physicians (AAFP), concluded the proceedings by speaking on the challenges and opportunities in sustainably supporting value-based payment in primary care.

Despite spending more of its gross domestic product on health care than any other country, the United States continues to rank last among high-income nations in measures of health care affordability, administrative efficiency, equity, and outcomes.³ A major issue perpetuating these disparities in health system performance continues to be the underinvestment in primary care, Johnson noted.

Whereas international high-performing health systems allocate an estimated 12% to 17% of their total spend to primary care, the United States invests approximately half that proportion at best, with only 6% of its spending invested in primary care.⁴

“Clearly the practices that are delivering primary care are [often] not well resourced and that leads to workforce burnout, which leads to workforce reductions. If we learned anything through COVID-19, [it should be that] primary care practices are [operating] on razor-thin margins and really couldn’t sustain the kind of stress that the pandemic brought—that’s exacerbating the patient access problem as well,” Johnson said. “And of course, that’s leading to some equity issues, because those gaps in care do not happen evenly and uniformly across the population.”

Overcoming decades of neglect and underresourcing in primary care requires not only more investment, but also different strategies on how to distribute available resources, Johnson explained.

“We really need to fundamentally change and recognize that to deliver really high-quality, comprehensive, continuous, coordinated, first-contact primary care, it requires a lot more than what you could ever write down or click on in a health record and document and pay for; it’s much more holistic than that,” she said.

With resource allocation cited by Johnson as the root cause of and solution for primary care inequities, her organization is leaning heavily on value-based payment to guide practices on how to optimally use their resources to improve quality of care. AAFP released several guiding principles for primary care payment:

• Pay prospectively to support team-based care
• Actively engage patients in the accountable relationship
• Risk adjust payment for medical and social complexity
• Evaluate what matters to patients and physicians
• Equip primary care teams with timely information
• Reward year-over-year improvement as well as sustained high performance

“While shared savings is a great model to get started, you cannot live on savings forever, because you will reach a level of high sustained performance and you will not be able to continue to do that,” Johnson noted. “And this is why the model leads heavily into population-based payments. The degree of risk that you want to take under that population-based payment should be flexible, but we think it’s an important model.”

Another challenge for health care stakeholders taking on VBC is maintaining communication and alignment with the myriad of benefit design decision makers in health care, including employers (both self-insured and fully insured) and traditional Medicare, Medicare Advantage, and Medicaid programs.

Progress has been made over the past decade regarding participation in alternative payment models vs FFS, but these models are largely built on FFS infrastructure, Johnson said, and adoption of population-based payment models continues to lag. As FFS is still embedded in the health care system, she explained that providers cannot simply step away from these payment systems but instead can continue to strengthen, increase, and ensure uptake of value-based incentives.

“One of the things AAFP has been doing is talking to practices and physicians who are doing value-based payment, doing it well, and having a really great experience with it. That’s because we are hearing that it is often us—our members and family physicians—who are sometimes the most reluctant to take this on [because] they’re overwhelmed and suffering burnout,” she said. “There’s this fear that VBC is more work. [In actuality,] it’s not that it’s no work, but it’s better work. It’s the work physicians want to do. It works and patients love it.”

REFERENCES

1. First, do no harm: calculating health care waste in Washington State. Washington Health Alliance. February 1, 2018. Accessed March 14, 2023. https://wacommunitycheckup.org/media/47156/2018-first-do-no-harm.pdf

2. Inserro A. Value-based primary care providers try new strategies to improve population health. The American Journal of Managed Care. December 15, 2022. Accessed March 14, 2023. https://www.ajmc.com/view/value-based-primary-care-providers-try-new-strategies-to-improve-population-health

3. Schneider EC, Shah A, Doty MM, Tikkanen R, Fields K, Williams RD II. Mirror, mirror 2021: reflecting poorly. The Commonwealth Fund. August 4, 2021. Accessed March 14, 2023. https://bit.ly/4193gvB

4. Jabbarpour Y, Greiner A, Jetty A, et al. Investing in primary care: a state-level analysis. Milbank Memorial Fund. July 19, 2019. Accessed March 14, 2023. https://www.milbank.org/publications/investing-in-primary-care-a-state-level-analysis