Top 50 Value-Based Care Thinkers of 2022

Gerry Ibay

Gerry Ibay

Vice Chair and Assistant Professor, University of Oklahoma Health Sciences Center

A female doctor sits at her desk and chats to an elderly female patient while looking at her test results

2022 is poised to be a big year for value-based care (VBC). The Centers for Medicare & Medicaid Services (CMS) and the Center for Medicare and Medicaid Innovation (CMMI) have charted a course toward VBC and away from traditional fee-for-service (FFS). January 1 of this year marked the start of the five-year performance period of CMS’s Direct Contracting program, the latest evolution of risk-sharing arrangements to produce value and high-quality healthcare. The rest of 2022 should see further continuance of VBC-related activities throughout the healthcare industry. We asked some of the top VBC thinkers to share their thoughts on the challenges and opportunities presented by this evolving approach.

Value-based care is here to stay

What is VBC?

VBC is care delivery focused primarily on quality versus quantity; it’s healthcare where value takes precedence over volume. VBC programs incentivize healthcare providers toward aligned goals. Instead of focusing on billable events, providers can partner with patients and their families as well as other care team members on the highest leverage solutions to complex health issues.

Inherent in the VBC incentive structure is risk. But savvy providers understand there is also risk in continuing with the status quo and are comfortable taking on risk to embrace the correlating opportunities allowed. For these providers and their practices, risk means freedom. Risk provides a path toward autonomy. Perhaps somewhat counterintuitively, risk enables providers to take back control of their practice.

Why the shift towards VBC?

Our current healthcare system is not working. Compared to our peer countries, we have higher costs and worse outcomes. And our healthcare system is fraught with inequities. While some Americans have access to the best healthcare in the world, for too many others the system is inaccessible, unaffordable, and dangerous. While the effects of our current FFS system are readily apparent, the inertia within the healthcare system makes change difficult. Yubin Park, Chief Analytics Officer at ApolloMed, states the situation succinctly: “Fee-for-service is a form of addiction; we know it’s bad but difficult to quit (opinions are mine and not necessarily representative of the company).” To be sure, the transformation from FFS to VBC will be difficult, but it will be worth it.

Fee-for-service is a form of addiction; we know it's bad but difficult to quit.”
Yubin Park
Yubin Park
Chief Analytics Officer
ApolloMed
VBC supports efforts toward achieving the Quadruple Aim of providing better care for individuals, improving population health management strategies, reducing healthcare costs, and enhancing caregiver well-being. Better care for individuals is enabled by allowing providers to provide personalized services in the most appropriate and efficient delivery settings. Better health for populations is enabled through the focus on population health including prioritizing preventive care. Lower cost is enabled through technological advancements in cost transparency and interoperability. Provider well-being is enabled by democratizing access to risk and opportunity. “Value-based care will enable us to transform our system,” says Stephanie Quinn, Senior Vice President, Advocacy, Practice Advancement and Policy for the American Academy of Family Physicians (AAFP), from “one that improves the health of a patient to one that improves the health of populations. We know that primary care plays a central role in the transition to value-based care and is foundational to the successful creation of a system that delivers high-value.”

Why VBC is here to stay

  1. Where Medicare goes, healthcare goes. A decade ago, CMS responded to legislative changes such as the Affordable Care Act by implementing the first of many value-based programs. From the hospital readmission reduction program to accountable care organizations, the government is determined to enhance value in the healthcare system. As the largest payer of healthcare services, where CMS goes, the rest of the industry follows. VBC generally and Direct Contracting specifically are part of CMS’s larger quality strategy to reform the delivery and financing of healthcare to support the quadruple aims mentioned above. CMMI’s goal is for the vast majority of all Medicare beneficiaries and all Medicare beneficiaries with Parts A and B to be in a care relationship with accountability for quality and total cost of care by 2030.1
  2. Alignment of incentives. VBC aligns incentives around performance, shifting the focus away from the traditional FFS model. When providers are incentivized properly, they can focus their time on the activities that provide the best evidence- and experience-based outcomes. As Dave Chase, Chief Archaeologist, Co-founder & CEO of Health Rosetta notes: “Healthcare isn’t expensive. After all, clinicians only receive $0.27 of every $1 ostensibly spent on healthcare. What’s expensive is price-gouging, profiteering, administrative bloat, fraud and inappropriate care. Those focused on value choose to not participate in those schemes.” VBC offers a path to participate in care relationships with shared accountability for quality and total cost of care enabled through aligned incentives.
  3. Maturity of the health technology ecosystem. The CMS Interoperability and Patient Access Rule has resulted in yet another iteration toward data-enabled decision making.2 With technology advancements providing greater actionable insights, health care providers can better understand the total cost of care and how they can affect positive changes that benefit their patients, their practices, and the entire healthcare system.
Healthcare isn't expensive. After all, clinicians only receive $0.27 of every $1 ostensibly spent on healthcare.”
Dave Chase
Dave Chase
Chief Archeologist, Co-founder & CEO
Health Rosetta

Challenges facing primary care practices under value-based care

The benefits made available through VBC are not inevitable. Valinda Rutledge, Chief Corporate Affairs Officer at Upstream Care cautions that “many challenges still face primary care providers in the transition toward value-based care that must be addressed as we seek to reform the healthcare system toward rewarding for value over volume.”

Payer-provider misalignment

A key challenge in succeeding under value-based care involves payer and provider alignment. Valinda Rutledge highlights this as a key challenge, expressing that “the quality of care provided by physicians must be accounted for while increasing the number of patients receiving coverage in the most responsible and feasible way possible. Maintaining the partnership between plans and providers in supporting the move to value-based care is another integral part of the movement toward value and creating strong incentives that encourage health plans to support these models must also be created for the improvement of the healthcare delivery system overall.” Stephanie Quinn echoes this point, noting that “few entry points and model availability in certain areas of the country coupled with a lack of alignment from payers and other stakeholders pose real barriers to a rapid movement toward value-based care.”
The quality of care provided by physicians must be accounted for while increasing the number of patients receiving coverage in the most responsible and feasible way possible.”
Valinda Rutledge
Valinda Rutledge
Chief Corporate Affairs Officer
Upstream Care

Data complexity and inaccessibility

While recent legislation and marketplace results have produced great gains in interoperability and data transparency, for many primary care practices, these advancements are inaccessible. They simply don’t have the resources to access these technologies or don’t have the time or expertise to sift through byzantine data files to find meaningful solutions.

Opacity around total cost of care

While primary care physicians are responsible for influencing millions of dollars of spending toward a patient’s total cost of care, they typically are only aware of their direct expenses related to the patient’s care journey. The opacity of the costs a provider’s panel of patients incurs limits the provider from allocating time and energy toward high-leverage activities that serve everyone’s best interests.

Disjointed care team approach

For many primary care practices, the healthcare ecosystem is too complex to provide continuity of care for their patients. There are too many specialists aligned with too many different payer arrangements that change too frequently. Primary care practices can often feel like they’re playing a game where the rules are constantly changing.

Keys to success for primary care practices under value-based care

Despite the challenges facing primary care practices, the transition to value-based care is not only possible, but is becoming increasingly manageable due to changes throughout the healthcare industry. Stephanie Quinn points out that “to be successful, practices must have the resources – technology and human – to care for their patients. Stable revenue streams and real-time, actionable patient-level data will create efficiencies and lead to better health outcomes and experiences. The AAFP is working with family medicine practices across the country to ensure patients get the best care possible.”

Stable revenue streams and real-time, actionable patient-level data will create efficiencies and lead to better health outcomes and experiences.”
Stephanie Quinn
Stephanie Quinn
Senior Vice President, Advocacy, Practice Advancement and Policy, American Academy of Family Physicians (AAFP)

Tighter payer-provider alignment

With CMS taking a strong stance regarding the movement toward VBC, other payers are recognizing the need to transition their business models accordingly. We’ve seen how health policy can serve as a catalyst for system transformation. Because healthcare is such a large and complex industry, change happens incrementally – but change does happen. Most payers understand the inevitability of VBC and are deciding to proactively align with providers instead of waiting until it’s too late. For primary care practices, now is the time to realign payer contracts to take advantage of these changing dynamics.

Integrated technology layer

Fortunately for primary care practices, there are various organizations providing actionable analytics that take advantage of technological advances in interoperability and data transparency – at a reasonable price and via user-friendly, intuitive interfaces. The combination of increased access and practicality of these technology resources allows primary care practices to better monitor and evaluate how their workflows affect the ultimate purpose of their efforts: providing high-reliable services for their patients and communities. 

Transparency regarding total cost of care

As CMS further doubles down on value based programs, it ushers in a new era of transparency regarding the total cost of care. Primary care practices can take advantage of more frequent, timely cost reporting to inform real-time decisions. For example, if a practice identifies a cohort of patients experiencing higher hospital readmission rates, it can take proactive steps to implement a more comprehensive post-discharge care planning process. It’s very likely any expenses related to the enhanced care planning will be more than offset by the reduction in readmission spending. Whereas before VBC, primary practices were primarily shielded from costs such as those related to readmissions, the future will see increasing accountability and shared rewards realized by primary care practices that can effectively manage the total cost of care.

As total cost of care becomes more transparent, primary care practices will be able to benchmark against their peers. This can both inspire and challenge practices to leverage community knowledge and experience. Ultimately, transparency makes the entire healthcare system more accountable for value. And it will reward those practices that embrace rather than run from accountability and opportunity.

Integration with care team network

The transformation of the healthcare system will take the combined efforts of all stakeholders. Primary care practices can identify new partners who are similarly aligned around value creation. A strength of the Direct Contracting model is that it encourages the formation of networks of aligned specialists and other providers while also maintaining choice for patients. Providers can identify specialists who demonstrate high-quality, low-cost care while allowing for true patient-centered autonomy. They can work with an ever-growing cadre of partners who provide disease-specific tools to manage cohorts of patients. Through open, transparent communication, providers and patients can co-manage complex clinical and personal issues and make decisions that achieve the Quadruple Aim in a respectful, sustainable manner. “In value-based care,” notes Dave Chase, “the most important “medical instrument” is communication. Communication among all members of the care team, especially the most important member (the individual — aka patient), ensures optimal health outcomes.”

Conclusion

VBC shifts the conversation from “what’s reimbursable” to “what works.” It provides a new challenge for all health care stakeholders to reimagine healthcare. It provides new mechanisms to support true practice transformation, such as stable, predictable payments to manage patients instead of a focus on encounters. It provides a vision for the future of healthcare – a future defined by value and enabled through aligned incentives throughout the healthcare ecosystem.

Christopher Chen, MD, CEO of ChenMed, highlights the opportunities of VBC for primary care: “Value-based care is the key underpinning of our ability to solve physician burnout, health inequities, and lack of affordability. The winners in the status quo fee-for-service system won’t drive change, but primary care doctors can lead the way. With a payment shift and technology built for managing health, primary care can be equipped to take accountability for the whole patient.”

Value-based care is the key underpinning of our ability to solve physician burnout, health inequities, and lack of affordability.”
Dr. Christopher Chen
Dr. Christopher Chen
Chief Executive Officer
ChenMed

At Pearl Health, we’re helping shepherd the industry along this changing landscape. We help by democratizing access to value in healthcare. We help by providing actionable insights through a robust technology platform. We help by enabling access and visibility into healthcare cost and performance. We help by fostering coordinated care team network development. We help by sharing evidence- and experience-based best practices and supporting practice-level implementation.

We’re honored to have had some of the top VBC thinkers share their thoughts around this topic. Fortunately for everyone involved with and affected by the healthcare system, there are numerous voices speaking up for a value-driven approach to health and healthcare.

Here’s our list of the top 50 VBC thinkers of 2022.3

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