Humans in Healthcare #35 | Value-Based Care 2.0, Part 2

Hi friend, Amy here, your authentically honest full-stop human, community builder, and creator of Humans in Healthcare, sharing the stories and experiences of healthcare professionals, patients, and caregivers. Today’s chapter is sponsored by Timeless Autonomy and Dana Strauss, PT, DPT as part of my clinician creator spotlight where I highlight clinicians building newsletters, podcasts, products, services, and beyond. Are you a clinician creator and want to sponsor this newsletter for more eyes on your product or services? Complete your application below.

Dana Strauss is the author of the Timeless Autonomy, a newsletter focused on value-based care. She is a PT turned expert in health care payment and alternative payment models, acute and post-acute care, home-based care, and care transitions. She works as a health policy analyst for a Fortune 10 company, where she leads VBC policy focused on Medicare and Medicare Advantage payers.

Today, Dana is sharing Part 2 in the series Value-Based Care 2.0. Below, she provides expert tips on how health tech companies can approach showing value to payers, providers, and patients when building solutions in the value-based care space. Enjoy!

📖 Value-Based Care 2.0: what health tech startups need to know about showing value to payers, providers, and patients

Value-based care is still both young and full of opportunity. There’s so much left to fix in healthcare, and between new payment incentives and technology, health tech companies can develop solutions for the three P’s: payers, providers, and patients.

The continuum of VBC engagement by all parties varies greatly from zero to full risk, and there is so much yet to be solved. VBC is a young toddler, if not still an infant. 👶 

While value-based care aligns the interests of three P’s, solutions are often sold to just one or two of the P’s. To be competitive, be a solution that spells out your value to all three.

Payers

Whether it’s the federal government as the payer, states, commercial insurance, or private pay…the cat’s out of the bag. They know it’s possible to care for patients better, more effectively and efficiently, more upstream, and more proactively.

They also know that a patient engaged proactively in the health system is more likely to manage their health and seek preventative care and that MANY reasons for high cost, poor quality, and poor value spending are the result of non-medical drivers.

So the payers’ challenge is that they don’t provide care.

I know, it’s obvious.

But when the person paying isn’t the patient, expecting something specific in return, it removes the comfort, or the assurance, that what’s billed is what’s needed. What’s actually NEEDED is what’s going to lead to early detection, management of diseases, health habit development, alternatives to hospital and ER care that have a cascading spend effect, and referrals to other high-value providers.

The provider, who in fee-for-service makes a living by quantity of billable care, procedures, and services, is not incentivized to save money or provide efficient care for the payer of services, specifically because it’s usually a third party.

Have you ever heard a provider say something like “We don’t want to order an MRI at that high-cost center because we want to save the payer money?”

It’s funny, isn’t it?

Showing value to a payer

First, make sure you know what the payer’s goals and pain points are.

• Are they developing high-value networks?

• What types of beneficiaries are they serving?

• Is there a lot of patient churn?

• Are they struggling because of quality scores?

• What levers are available?

Second, know how far they are in value-based care arrangements and in what product segments. Surface opportunities to make progress to the next step. Remind them of the future state and why it’s inevitable.

An example:

If your product offers a way for primary care providers to identify, refer, and communicate with the most high-value specialists and other clinical and service solutions and are pitching to the payer to reimburse 100% of the cost of these services, consider demonstrating:

• why and how the provider will embrace the solution?

• how it will improve their operations, and how it supports payer/provider alignment.

• how patients will experience the results of the provider using this tool

• will the high-value specialist connect more meaningfully with the patient?

• will the patient feel more seen, heard, and cared for when the primary care practice reaches out after the specialist is called to coordinate care?

• how likely would it be for a patient who feels part of the care team to remain a loyal customer of that primary care provider?

• how likely will they be to reach out sooner when they don’t feel well rather than waiting until they need the ER?

How does your product facilitate a flywheel effect? Engaged and loyal patients, enthusiastic, committed providers, and flexible and responsive payers foster engaged and loyal patients.

Providers

Providers can be more resistant to change. The move to VBC has been driven largely by payers. You are painting a picture of the inevitable future state. Providers are on a spectrum of acceptance of this reality.

Primary care providers taking full financial risk for a population, especially the Medicare population, have developed a framework for success. The Medicare population is more stable in terms of which patients are part of which payer. There are those in FFS and then the Medicare Advantage population. In full-risk models with high-value providers, patients are also getting high-quality experiences that make them more likely to commit to the same payer year over year.

In full financial risk, providers typically build care teams, support patients’ multidimensional medical and non-medical social determinants of health, do more proactive outreach to patients, and put systems in place to facilitate hospital avoidance at all costs.

They build primary specialty care into their practice, work with high-value specialists, and collaborate closely with all others who provide care and services. They may engage in provider to provider e-consults. They are paid to cover the total cost of care of the patient for the calendar year and do everything they can to help avoid high-cost, low-quality utilization. They often spend much more on primary care-related services than a typical practice. The way they practice doesn’t resemble the care most of us are used to. Patients are generally happy and engaged, feel heard, and feel better.

These types of providers exist in pockets, but this is only the beginning. Solutions have to scale and get to the masses.

Showing value to Providers

Develop and present solutions to primary care providers and teams considering the following:

Providers can be wary of Artificial Intelligence (AI). Ease those fears by shifting the narrative. De-mystify AI. Demonstrate examples of AI solving problems that help patients they can’t reach easily. Such as:

• AI makes humans smarter. It allows providers to scale their care, better engage patients, and provide “just in time” contact.

• AI democratizes access to care.

• AI saves lives. An example today is being able to identify teens at risk of suicide by changes in their responses to questions.

• AI solves workforce issues and variability issues.

• AI allows care coordinators to reach out to the right patients at the right time and makes the experience for the coordinator more satisfying.

Most of what drives health outcomes is related to non-medical or social determinants of health. Demonstrate how your product does what providers can’t:

• Can your product connect the right patient to the right community support?

• Can your product assist with transportation, in-home access, or remote access to care?

Providers are pitched solutions that may meet one need well, but either don’t play well with other fixed tools and workflows already in place or are too limited in their future scope of applicability.

• Ensure your product makes operations and workflow more intuitive and simpler, and articulate how.

• Predict future needs and share how your product will be adapted to meet those needs (example-as interoperability requirements change, what does that mean for your product?)

• Can your product eliminate boring, unsatisfying work? Can it make the quality of work in the office more consistent across the board?

Predict the quality metrics of the future. CMS is interested in aligning quality measures across all payers. How does the future of quality, including a move away from process measures, help you demonstrate the value of your product?

• The more we move to outcomes-based quality measures, the more providers have to lean into care transformation.

• Quality metrics we could see more consistently, especially when providers are paid prospectively, per member per month, capitated:

  • Days at home per year

  • Care received at home vs. in a facility

  • Patient-reported outcomes measures

• Quality measures of the future will likely move fully off of “process” measures, like reporting the number of diabetic eye exams completed in the relevant population, and colonoscopies, mammographies, etc, because payment and penalties are so dependent on high-quality disease management and early detection, that process metrics have to be good to be successful.

Use patient examples.

• Patient examples are so incredibly powerful in demonstrating the value of a solution and/or service.

• Providers/health systems/clinicians very commonly collect and share patient stories to keep everyone focused on the mission, the long-term goals, and the “why.”

• Most want to partner with technology vendors who understand that. They show the results that align with their goals, and they know what fits their culture.

Patients

Let’s back up and think about what patients care about. What do you care about when choosing and remaining loyal to a physician practice? You should directly point these out to a practice if they fit with your solution.

Showing value to a patient

• Does your product make it simple for patients to communicate with their providers? Patients want their chosen method to be available, whatever that is. Same with communicating with the payer. It should be simple and reliable.

• Does it address access to care? Zero to minimal wait time for urgent issues. If I perceive them as urgent, they are urgent, and I want to be able to ask someone.

• Does the product improve operations for staff and providers so they can take more time and be more human with their patients?

• Does the solution make calling, texting, or messaging to follow up on visits simple? Can the practice easily send information, contact me, and coordinate with my other providers?

• Does the solution allow patients to use their health insurance benefits wisely and does that use drive good outcomes? If a patient’s benefits include non-medical, supplemental benefits, can the product help match the patient's needs to the benefits available?

Putting the 3 P’s together

Here’s an example of showing value to the provider, patient, and payor when selling a patient engagement tool to a primary care practice:

“Our patient engagement tool eases the burden on the practice and reduces variability.” (1st P: provider).

and

“Our patient engagement tool automates an enjoyable, patient-centered experience, improving compliance, loyalty to the practice, trust, and engagement. It improves the quality of care and outcomes by making it easy and enjoyable for your patients to stay close to the practice and providers” (2nd P: patient).

and

“Our patient engagement tool reduces the likelihood a patient will seek emergency room care when they just need urgent care access. It ensures changes in their condition are caught early before decompensation is so significant that they need a hospital stay. That reduces the likelihood of not just the hospital stay, but additional post-acute care and the risks and complications inherent in transitions of care and post-acute care.” (3 P: payer).

Bonus: other considerations to make you and your product competitive in the VBC space

Stay up to date on policy and regulatory barriers and opportunities and what’s on the horizon. Be a visionary and make the vision make sense. Paint a picture of the path.

Be transparent about your roadmap. Be honest. Don’t sell what’s not built yet.

Build into your offering direct support for implementation and problem-solving.

Create a newsletter and share it with prospects and clients. Provide tremendous value. Be a thought leader. Make them proud to work with you.

If you don’t have clinicians on your team as you build, refine, develop your roadmap, support implementation, add them.

And regarding clinicians, here’s a great place to find talent!

Thank you Dana for sharing your insights and knowledge and helping us step into the future of VBC. Be sure to stay updated on health policy news and educational opportunities from Dana, delivered right to your inbox!

In humanity,

Amy

Dana is hosting a VBC workshop for members of the Humans in Healthcare community. Are you a clinician interested in joining a space where we regularly host office hours and workshops on a variety of topics related to clinicians, creativity, and humanity?

Are you a healthcare professional, patient, or caregiver and want to share your story?