Post-election, the rallying cry in Washington DC is “all change” for coverage, payments, costs, and public health. But while lawmakers debate the future, innovative care delivery models are being tried out right now around the country—and those experiments will likely continue regardless of what happens in Congress.
Health policy expert Kavita Patel, MD, a non-resident fellow of the Brookings Institution and an internist at Johns Hopkins Medicine, says it won't be all that easy to unravel the Affordable Care Act. Also, as health reform once again comes before Congress, Republican and Democratic lawmakers do share a few common values around cost and payment reform that might potentially lead to a coming together on at least some policy prescriptions.
Dr. Patel, formerly director of policy for the Office of Intergovernmental Affairs and Public Engagement under President Obama, was the keynote speaker at the 27th Annual Symposium on Health Care Services in New York on November 15, jointly sponsored by United Hospital Fund and the GNYHA Foundation. She laid out two competing cost and payment visions among policymakers: large integrated provider networks that reward value over quantity, versus consumer-driven markets in which high-deductible health plans bring market forces to bear on costs.
The integrated model is winning with providers. As Dr. Patel said, “the people who are true believers in integration are taking over.” Surveys show that physicians who have moved toward integration and away from fee-for-service are largely happy with the change.
That could be why value-based payments are slowly edging out fee-for-service reimbursement, and are likely here to stay. In California and Massachusetts, more than 40 percent of payments are value based, though for the nation overall it's only 10.9 percent. Dr. Patel cautioned, however, that “the majority of what I see that's described as a value-based payment is just a step above fee-for-service.”
An independent scorecard of health care payments in New York State shows that they continue to flow through a fee-for-service mechanism in both the commercial (94 percent) and Medicaid (72 percent) sectors. However, approximately one-third of health care payments to doctors and hospitals in New York State are at least “value-oriented.” Also, a New York State Dept. of Health survey of 56 health care plans found that 25.5 percent met some criteria of value-based payments in 2014.
Despite the relatively slow uptake of value-based payments—or because of it—there are a myriad of care-delivery experiments throughout the U.S. that are attempting to improve both costs and quality. Project ECHO, based in New Mexico, is linking academic medical centers with rural clinics via telemedicine, creating a new approach to care. Launched in 2003, ECHO grew out of the vision of Dr. Sanjeev Arora, a liver disease specialist at the University of New Mexico Health Sciences Center in Albuquerque. He was frustrated that only 5 percent of the state's 36,000 people diagnosed with hepatitis C were in treatment, and only two clinics in the state had the necessary expertise. Arora assembled a multidisciplinary team in Albuquerque to host weekly teleECHO clinics via videoconference for primary care providers around the state. Primary care physicians present their patients' cases during these “virtual clinical rounds,” and the specialists in turn train them in the best course of treatment.
After the first clinic launched, the wait time for hepatitis C treatment in the state dropped from eight months to two weeks, and a study published in the New England Journal of Medicine demonstrated that the quality of care was excellent. Project ECHO now has over 50 hubs in the United States and covers a number of chronic diseases; primary care providers from every state have connected to a teleECHO clinic.
For-profit provider Iora Health operates all of its 13 primary care practices in six states on a value-based compensation model. Iora emphasizes preventive care, a close patient-doctor relationship, and technology tools to coordinate care, all for a flat monthly fee. It reports a 20 percent improvement in outcomes and an 18 percent reduction in costs for its patients.
Any new payment models will likely carry some financial risk. Health care leaders must ask themselves what assets and competencies they need to manage that risk. And they must keep in mind that, despite all this uncertainty, the health community is united in a shared purpose—high-quality, affordable care for all—that may help to ease the way forward.