Editor’s note: Troy Williams is vice president of healthcare systems partnerships for First Choice Health, a provider-owned healthcare organization offering alternatives to traditional health insurance.
While there are endless trends to prognosticate about in the healthcare world, one that is near impossible to quarrel with is that the push to value-based care will not only continue, but accelerate.
Amid all of the transformation, innovation and buzzwords in value-based care, one crucial area that is suspiciously absent is the emergency department. But before delving into why this may be the case, it’s worth taking a step back to look at how we got to this point.
Over the past two decades, and now exaggerated by an ongoing pandemic, healthcare has solidified itself as one of the most visible social and economic issues in the U.S. Providers and payers have traditionally focused on the payment and legal changes required to move healthcare forward. More recently, that focus has shifted to how the private sector has responded and shifted to answer new challenges.
2018 was a notable year, with a number of organizations placing bets on healthcare transformation and announcing new deals and offering combinations that paired corporations at different ends of the healthcare sector into “mega-corporations.” These surprised an industry that has historically pursued mergers and acquisitions via horizontal rather than vertical adjacencies, setting the table for new paradigms.
Ready, risk, reward: The value-based care training wheels come off
So that gets us to today. We can expect that, through the remainder of 2023, healthcare providers will alter their decision-making matrix from if they will take the leap toward assuming risk to when they will do so. Getting there has meant the introduction of new programs that qualify as alternate payment models, giving providers more options for participation — with two important changes.
First, as models demonstrate success in terms of cost and quality improvements, we expect a shift away from voluntary programs in favor of mandatory participation. Second, there will be stricter limits on upside-only models, eventually eliminating these options completely.
The days of dabbling in value-based care are over; the tipping point for providers to enter into APMs has occurred. This allows greater differentiation for two-sided risk models that hold participants accountable for losses incurred. Some may resist, but the options afforded by many payers will increasingly narrow.
Value-based care concepts are finally appearing in many commercial arrangements — though it doesn’t mean that all providers are comfortable in this space, nor does it mean that hospitals and clinical providers are entering into dual-sided risk arrangements with fervor. It does, however, give some indication of how the landscape has changed and what’s coming next.
Whether it’s through bundled episodes, concierge medicine, direct primary care, patient-centered medical homes or worksite health and wellness, employers have embraced the new offerings, and the provider systems on board and well practiced are beginning to adapt clinical workflow, business infrastructure, reporting and analytics to align incentives with those of their health plans and patients.
More options, no change
It’s curious that with so many new options, including the older fee-for-service model, we still can’t take the pressure off the front door of our hospitals, namely the emergency department. While it is not surprising that emergency departments hit capacity during the peaks of COVID-19, actual demand started way before the pandemic.
Limited availability to accept new patients and closed panels have had a profound impact on ED utilization. Multiple access points, including virtual and digital tools are potential solutions, but only if adoption and engagement are consistent. A boom in telehealth visits early in the pandemic was soon met with a sharp decline with patients historically feeling more well served in face-to-face settings. Even more crucial is that digital options cannot simply be another point solution — it must be integrated with the system and care team.
A recent study showed that value-based care can drive down acute care episodes such as hospitalizations and emergency room visits among Medicare Advantage beneficiaries. The research found MA members treated by doctors in advanced value-based care models saw 15.6% fewer hospitalizations and 13.4% fewer emergency department visits compared to those treated in fee-for-service arrangements.
Priorities that should speed the shift to VBC through the ED include integrating quality and resource use measures across all healthcare delivery settings and populations, encouraging care coordination from the ED and implementing robust health information exchange systems.
Understanding how the ED is being utilized by a specific population can give insight into meaningful behavior. For example, is the ED being used instead of the primary care office? Can it be used as a dumping ground, allowing physicians and clinical teams to get back to the work at hand, leaving the ED to sort things out? Do patients and their families have access to convenient care for urgent and non-emergent issues, with after hours availability and pediatric services on the weekend?
Transition management that ensures patients who may be attributed to VBC-based plans can have a also profound impact in ensuring that following discharge patients have connectivity to their PCP’s or specialist’s office. Referral patterns here will be incredibly important. Willing affiliates taking on these patients have to follow governance to best accommodate the accountability under the contract terms. Significant costs can be avoided with strong clinical pathways, home health resources, care coordination and sharing of data.
Navigating the healthcare landscape is difficult enough for any patient or family member without the presence of compounding and overcomplicating healthcare logistics during a significant healthcare episode. Whether health systems and their emergency departments catch up with the value-based care wave in 2023 or continue to lag far behind, it will be vital to consider all of the above to ensure there are no surprises in the experience for patients or providers alike.
