Value-based Care Industry Update – Elevance Health & Integration Opportunities – Part 1

We should acknowledge that value-based care doesn’t have an universal definition. It’s getting more defined, but there are important stakeholders within the healthcare industry that view the term differently. Some view it as performance, reporting analytics or infrastructure, while others note that these models may fall short of delivering value in terms of quality or affordability, and they don’t remedy the problems for fee-for-service. What is your definition of value-based care?

We talked about pop health and highlighted that PMPM [per member per month] is the most extreme form of value-based care in terms of capitation, but there are also the incentives. PMPM ties into pop health elegantly in that those who are most vulnerable, who need preventative care or predictive medicine, would receive care to avoid more costly expenses and re-admissions. We continue to discuss health equity. I conducted an Interview on a private company with a mission to actively treat the most vulnerable in order to lower system costs – to reduce repeat ER visits. Improper care is impacting provider margins and creating a less healthy society. When we embrace the view that commercial payers and CMS [Centers for Medicare & Medicaid Services] collectively cover the whole of society, providers should be incentivised to care for the most vulnerable. We much adopt a much healthier mindset in how we take care of people in our society through predictive medicine and preventative care. Could you opine on that?

Migration from fee-for-service to value-based care models has been an important initiative for over a decade. What have been some of the major challenges preventing greater progress? It seems that only now are we seeing greater momentum. I know there were some prerequisites such as EMRs [electronic medical records] and the digitalisation of healthcare. What has prevented greater progress, and what’s occurring now that’s allowing us to finally see the change that we’ve all wanted?

Regarding the consolidation on the provider side, you did have a lot of struggling community hospitals that just didn’t have the budget to invest appropriately. I wonder if the potential challenges due to the ACA [Affordable Care Act] forced a lot of providers towards consolidation in order to gain access to professionalised leadership that could better manage risk. Was that part of the realisation by some providers, thinking they needed to join bigger provider networks to successfully operate in this new era?

We talked about some of the major challenges preventing greater progress in the adoption of value-based care, but seeing momentum building. Value-based care is spreading. What is finally allowing value-based care to be more fully embraced? Is it the fact that there are so many more providers that have invested appropriately in the analytics we’ve discussed to enable better risk management?

Who do you believe are the greatest advocates regarding value-based care? Would you share your experience with managed care organisations? What exactly are they doing to drive value-based care adoption?

How do you think CMS is doing as an advocate for value-based care adoption? Its innovation centre issued an ambitious goal of shifting 100% of Medicare beneficiaries into accountable care relationships by 2030. It seems CMS is a strong advocate for value-based care adoption, which conceptually makes sense, except for the bureaucracy and policies that are so entrenched in fee-for-service. In terms of practically in executing this, how difficult is it to change. Though I would imagine that CMS is philosophically on board with value-based care, is it actually one of the biggest obstacles to value-based care advancing?