Panel: COVID-19 Presents Opportunity to Reform Health Care Payment, Delivery

During a 2021 AcademyHealth National Health Policy Conference session, members of The Commonwealth Fund Task Force on Payment and Delivery System Reform discussed policy recommendations aimed at preparing the United States for future pandemics and addressing care inequities brought to light by the coronavirus disease 2019 (COVID-19) crisis.

David Blumenthal, MD, MPP, president of The Commonwealth Fund, led the discussion, which included perspectives from Gregg Meyer, MD, MSc, president of the Community Division and executive vice president of Value Based Care for the Mass General Brigham health care system; Gail Wilensky, PhD, senior fellow at Project HOPE; and Vivian Lee, MD, PhD, MBA, president of Health Platforms at Verily Life Sciences.

In November 2020, the task force published a report on policy imperatives for health care delivery system reform based on real-world experience and available evidence. The 6 recommendations—devised with the aim of improving quality, advancing equity, and increasing affordability of health care—included:

• Increase health system preparedness
• Increase health system accountability for cost, quality, and equity of health care services
• Strengthen the underdeveloped primary care infrastructure
• Support the engagement of patients and communities in their care
• Reduce administrative burdens and costs
• Find a balance between the regulatory and competitive approaches in governing local health care markets

When it comes to the COVID-19 pandemic, “the truth of the matter is that for us to do anything short of learning all we can from this would be really adding a tragedy on top of one that's already occurred,” Meyer said. In order to best meet the next pandemic when it occurs, a preparedness program will not be sufficient, Meyer argued. Instead, what’s needed is a preparedness mindset.

In the report, experts called for the development of a national strategy to delineate a governance structure. Throughout the pandemic, “one of the things that we all experienced was there were times when no one was really sure who was the decider, and who was in charge,” Meyer said. “That's something that we can't afford to do again. We recommended that we delineate a governing structure with clear definitions of what local responsibilities are, what state responsibilities are, and federal responsibilities are during emergencies.”

However, in order to make these multilevel decisions, accurate and timely data are imperative, in addition to capacity and stockpiles already on hand when disaster strikes.

“I think a critical lesson that we've all learned is just the invaluable nature of data and sharing, to help make our national system a learning health system,” said Lee. To strengthen surveillance and better track epidemic and nonepidemic illnesses and their potential impact, the task force recommends the federal government form a national public health information system. This system can help in the rapid and secure exchange of electronic health information, Lee explained, but also can improve access to information by race and ethnicity. Health systems, payers, and other health entities could be required to share this data, whereas “developing federal requirements for national, state, and local authorities to collect and report those data on the potential and actual impact of disasters on people of color” is paramount in creating a preparedness mindset.

To address the health care inequities made apparent by the pandemic, the force called upon the federal government to develop a set of quality measures that includes performance measures to promote racial equity. These could include ensuring diversity of staff, health system–wide programs to foster equity, and health system data capacity to report social needs of diverse communities, in order to promote a level of trust in local health systems, Lee explained.

As more federal action on data surveillance takes form, so too will concerns on individual liberties and privacy. “It's absolutely essential that there are parameters for data use agreements for ensuring that systems align with protections to ensure civil liberties, due process, nondiscrimination, data, and health privacy,” Lee noted. “Those are all absolutely essential to maintaining the trust that we've seen so challenged across our wide diversity of communities.”

Turning to the subject of payment system reform, Wilensky stressed the importance of learning as much as possible from the pandemic. “It's really a question of how quickly we can accelerate the movement toward value-based care and also to transfer more of the financial risks to the delivery system,” she stated, adding that the crisis made the weakness of fee-for-service medicine apparent when there was no utilization taking place. “The reliance on fee-for-service medicine not only raised quality concerns, but also financial stability for individual physicians and for the delivery system itself.”

For the movement to value-based care to be successful, Wilensky underscored the importance of adopting 2-sided risk and gaining support from the federal government. Although change will not happen overnight, “we’ve all recognized that when we're forced to change in a hurry because of circumstances that are imposed on us, like being in a pandemic, the system is actually more adaptable and more flexible than some of us may have assumed prior to last spring,” she said.

Value-based care may also be part of the solution to making primary care more sustainable and more available. During the spring of 2020, “to the extent that payments were based on fee-for-service, when the volumes dropped down, essentially, to zero…there were doctors who were struggling to make payroll for the folks working in their practices, furloughing employees, shutting down sites, decreasing access,” Meyer said. Meanwhile, “those who had more of a stream of revenue based on capitated payments or subcapitated payments or other risk arrangements that fronted money to them, they were able to weather that storm much better.”

With regard to the question on which payment system is going to serve the industry better in a crisis, “it has been asked and answered by COVID-19,” he said. But ultimately, a hybrid approach including combined prospective payment approaches and modest levels of fee-for-service may best preserve the resilience of primary care practices yet ensure financial crunches may be met up the road.

“Delivery systems and physicians, groups of physicians, should be paid partly on the basis of the number of people that they take care of…but having part of the payment reflect the actual utilization of care is also important,” Wilensky said.

To better address health equity issues, payment and delivery models should be developed and tested in partnership with communities of color, Lee added.