Moving Toward Value-Based Care in Diabetes: Stakeholders Weigh In

There’s a consensus that valuebased healthcare makes sense, especially when managing a chronic disease. But how do practices move to a new system?

At Diabetes Innovation 2013, held in Washington, DC, and sponsored by the Joslin Diabetes Center, stakeholders from each part of the delivery system shared how the transition has worked for them.

Robert H. Groves, Jr, MD, senior medical director, clinical performance, Banner Health, discussed the challenges associated with forming a pioneer accountable care organization (ACO).

Grace Emerson Terrell, MD, chief executive officer and president, Cornerstone Health Care, offered her perspective as head of a multi-specialty provider group, outlining her organization’s plan for converting contracts from fee-for-service to 100% value-based.

Sam Ho, MD, chief medical officer and executive vice president, UnitedHealth Group, highlighted the importance of taking a multi-pronged approach toward changing the model of care to one that is patient-centered.

Jeremy Nobel, MD, MPH, adjunct leclecturer, Harvard School of Public Health, and medical director, Northeast Business Group on Health, offered an employer’s point of view.

Nobel began his presentation by saying the United States has 3 separate crises in diabetes: first, there is a very large risk pool; second, many who have diabetes are unaware; and, third, the nation has a high percentage of patients with diabetes who are not treated to target.

Labor economics, Nobel said, “is the driver for the point of view of self-insured employers.” Employers need to be able to attract and maintain a healthy, productive workforce. They also need affordable insurance. Labor economics “relates very dramatically to diabetes,” he said. He explained that high healthcare costs lead to higher-priced goods and services. “They lose business if they have to charge more for products because of spending too much on healthcare,” he said.

This pressure necessitates the employer’s active participation in promoting value-based care. Nobel described the 3 “levers” he said employers have concerning healthcare:

1. Influence over the delivery of care through contracts with providers that include metrics.

2. Benefit design that guides employees to make better decisions.

3. The ability to create and sustain a culture of health in the workplace (eg, availability of healthy food in the cafeteria, corporate support).

A Pioneer ACO

Banner Health is one of 32 pioneer ACOs selected by the Centers for Medicare & Medicaid Services through an application process. Banner Health comprises 13 hospitals and a network of affiliated physicians and other healthcare providers in Arizona.

The pioneer ACO model is a population healthbased model that has a greater degree of risk and savings than a standard ACO arrangement.

Groves told attendees that through the use of electronic medical records (EMRs), Banner Health has worked to implement a model based on clinical performance measures. One of the biggest challenges has been fragmentation, he said. There are dozens of quality measures, and there is no consensus on which ones should be used.

“By focusing on everything, we are in fact focusing on nothing because we are too scattered,” he said. “We need to choose the most important measures.” Groves advocated for a more consumer-driven model of care where “The first dollar belongs to the patient and they shop for healthcare themselves.”

Patients should also be able to share in the decision making with regard to their own care. Patients want to be able to have minimal disruption to their lives, and they have opinions as to what will work best for them. “Let them choose which medication side effect they would like to tolerate instead of us telling them,” Groves said. He added that there needs to be a greater focus on changing patient behavior, not just physician behavior. “If we don’t focus on behavior change in the population, other behavior change doesn’t matter,” he said.

A Physician-Owned Group Practice

Cornerstone Health Care is a 350-provider multi-specialty group practice owned by physicians, Terrell said. Cornerstone began transitioning from the traditional fee-for-service model in 2011 to a value-based, patient-centered medical home (PCMH) model. In 2012, Cornerstone formed an ACO. The goals were to improve quality of care, improve the patient experience, and reduce healthcare costs. “We decided to lead as quickly as possible to 100% value-based. We converted 100% of contracts to have a value component,” Terrell said.

This was a 3-pronged approach. Cornerstone had to change and redesign patient care, invest in new types of infrastructure, and, finally, pay for care in a different way. Terrell explained that patients were categorized by health status—healthy, at-risk, early chronic disease, end-stage chronic disease, or acute illness—each one of which was redesigned as a care model. “The highest cost among them is diabetes,” she said.

They started with “simple tools” and clinical data, such as cholesterol measurements, hemoglobin A1C, and blood pressure. They contacted those who were not at goal. “We hired some people to call them—customer service, patient care advocates,” she said. “It paid for itself in 6 months.”

She added that there are many types of healthcare resources other than physicians, such as analysts and health coaches. “The way we provide care is the tyranny of the 15-minute physician visit,” she stated. At Cornerstone Health Care, they operate as a team of healthcare professionals, including a nutritionist, a behavioral health professional, and a nurse practitioner, that helps patients work on their exercise and nutritional goals as well as on compliance. For patients with diabetes, their medications are free if they remain compliant. “We blew up the way we were providing care,” she said.

“We put them in a medical home with a team that works with them. It’s an hour or more for the first visit.”

A Health Plan

UnitedHealth Group committed to increasing the value of contracts it has with physicians and hospitals based on quality and cost efficiency measures. The health plan has been shifting its contracts away from fee-for-service to one that is more value-based. Data analytics, continuum of care, wellness, prevention, and treatment are all critical measures of purchasing value, Ho said. “Each one is insufficient by itself,” he added.

They started with 5 key levers:

1. A patient-centered model

2. Consumer engagement tools (eg, online portals)

3. Value-based insurance design

4. Practice transformation (ie, process plus culture)

Value-based incentives for providers

For diabetes, the health plan has 3 different value-based designs. For example, members can get a 20% discount on their premiums for meeting certain criteria, such as getting a foot examination or an eye examination.

There is also a personal rewards program based on meeting certain objectives connected to compliance and treatment goals. Ho explained that partnerships are also critical to success. Among other stakeholders, UnitedHealth has partnered with the YMCA and with community pharmacies. “The pharmacist is part of the team,” he said. It is also important to share data and share incentives. Value-based purchasing is nothing new, he said, but the shared commitment and collaboration across stakeholders is new. “We can’t do it alone.”