Speaking during a Sept. 15 eHealth Initiative panel discussion, Devdutta Sangvai, M.D., M.B.A., executive director of Duke Connected Care, said clinicians are under such stress during the pandemic that value-based care initiatives need to focus on enhancing efficiency to ease their burden. “If you can create efficiency in your value-based model, I think you're likely to get better provider mindshare,” he said.
Sangvai is vice president for population health management at Duke University Health System in North Carolina. He also is a professor of family medicine, pediatrics, and psychiatry at the Duke University School of Medicine and leads Duke Connected Care, Duke’s accountable care organization/clinically integrated network.
“COVID-19 has further stressed an already stressed system,” he explained. “As we're thinking about how we modify provider behavior and include new workflows into the delivery of care, it is being done under circumstances that I think modern healthcare has never really experienced before. Providers are stressed. But if you can figure out how to get from A to B in 10 steps, when it currently takes 12 steps, and in the process, deliver on value-based care, I think that's the formula that's going to get providers engaged. I think efficiency is going to be the new currency.”
Also speaking on the panel was Michael Barrett, vice president of strategy and development for payer Centene/WellCare, where he works with provider organizations on partnerships, including Medicare ACOs. He stressed the word “value” in value-based care. He said healthcare organizations need to do critical evaluations of what's valuable. “If it's not valuable, don't do it anymore,” he said. “Replace it with something that's more valuable. The system is so filled with low-value activities that it's a challenge to wade through the them all and convince people to stop doing those things, because they've always done it that way. Some of that is pure process. A lot of it is linked to clinicians wondering if they are going to make their next payroll.” He said there is a transition underway from driving the machine faster and faster — how many office visits can I get done today? — to a new mode of operation where you might intervene on a case where you avoid a hospitalization that costs $15,000. Closing that loop so the clinicians get paid for that work is the big challenge, he said.
Sangvai said that over the years Duke Connected Care has learned that in order to get providers on board, you have to make more than an economic case. “We know that there have been some ACOs that have performed remarkably well, for example, in the MSSP program, where the financial rewards really outpace anything you would have earned in a fee-for-service space,” he said. “But in a lot of ACOs, that's just not the case. To compel doctors and other providers to redesign the way they deliver care, you’ve got to give them more than just a financial model. In healthcare we can really run the fee-for-service engine as long and as hard as we want. Anytime we find a stressor, we just find a way to get another 10 percent out of that system. We really have to figure out how to change the system in a way that the answer to every financial stressor is not let's just do more fee for service, but actually redesign care.”
Both Barrett and Sangvai were asked, based on their experience, what they would focus on if they were starting a new accountable care program today.
“If I were launching a new program on January 1, the very first thing I would do is find out who has been admitted in the last 90 days,” Barrett said. “That is highly predictive that they're going to get admitted again within the next six months. It is a small enough number of people that I might actually be able to do something.” He said Centene had a program called 90/90/90: Who are the 90 percent of people who have a 90 percent chance of being admitted the next 90 days. “Go find them and talk to them,” he said.
Sangvai said that if you have identified an area where you have variations in care that don’t make sense, that's a good place to start. “Ask members of the healthcare team, what is it that you're witnessing in our group that just doesn't make sense. It could be Dr. A’s patients stay in the hospital for five days every time they're admitted for pneumonia, and Dr. B's stay for three days. As you think about where you have that variation, let's say it's in heart failure admissions, try to then understand why that variation exists. You want to set benchmarks, or at least one benchmark, and then implement one or two initiatives. Maybe it's post-discharge phone calls.”
He said it is important to identify one or two areas that you know either through your own internal benchmarking or as you compare yourself to others where you think you can perform better, and then figure out how you can actually implement the change. Most payers will likely come to you with a model that they have already implemented in other parts of your geography, and ask you to engage in that model.
Thinking back about what he might have done differently, Sangvai said one aspect involves setting expectations on getting better clinical outcomes and bringing the joy back to medicine, both for the patient and provider, and not focusing as much on ROI.
“I think it might have been a little bit easier to lay the initial groundwork that you can then build on and then look to get that return on investment,” he said. “Because you really have to build the system. The challenge, of course, is you're still up against the realities of how care is currently delivered, which is that fee-for-service model. We've all built our systems around that. We've heard all the different analogies we can make about changing the tire while the car is going down the highway. That's really part of the challenge. You have to think about what you are trying to achieve and try to scope that in a way that has a long vision, as opposed to maybe a one- or two-year ROI vision.”
