Healthcare policy leaders nationwide agree on one very broad principle: that the U.S. healthcare system needs to be guided, including via payment incentives, towards improving the overall health of the total U.S. population. Beyond that broad principle, there are countless perspectives and prescriptions out in the healthcare system right now, all of them contending for attention and approval.
Now, a team of healthcare policy researchers believes they have the right idea. In the article “Pay For What Matters To Patients: A Whole Health Population-Based Payment Approach,” published online in the “Forefront” section of Health Affairs on July 5, Sai Ma, Qui Zhou, and Shantanu Agrawal argue that, despite the dramatic proliferation of quality measures connected to health status and population health, “[R]ecent evidence of quality improvement is mixed,” with the article’s authors noting that, “As seen in the case of chronic conditions such as diabetes, despite the adoption of numerous discrete diabetes care measures, diabetes-related outcomes such as lower extremity amputation are still far from being optimal. This raises questions about whether we are measuring and incentivizing the right drivers of health. According to the Centers for Medicare and Medicaid Services’ (CMS’s) Innovation Center’s synthesis review of their 30 payment models launched in the past decade, most of the models did not demonstrate consistent and significant improvements in quality.” And that is despite massive investments of time, effort, and money into measurement processes; the researchers cite the example of one hospital that they note spent more than $5 million, “along with an additional expenditure of more than half a million dollars in vendor fees, for the preparation and report of 162 unique quality metrics in a single calendar year.”
With regard to all that, the researchers write that, “In recent years, there has been a growing interest in the concept of whole health in the public sectors such as the Veterans Affairs (VA) and private sectors including Elevance Health. This approach recognizes that an individual’s health is not simply the absence of diseases but rather a state of complete physical, mental, and social well-being that is determined by multiple factors. Clinical care only accounts for a small portion of a person’s health, while the majority of health is influenced by health-related behaviors, socioeconomic and physical environmental factors. The VA also emphasizes self-care and skills development as key components. With this in mind, a whole health value-based approach should address all major drivers to improve overall health. Here, we describe how a whole health population-based VBP arrangement can address the key aspects of value that payers, including CMS, should prioritize. Necessary conditions of a whole health VBP should include the following three components: all-inclusive services, resource integration, and outcome measures.”
In the researchers’ view, “A comprehensive approach to improving health could be achieved through all-inclusive services, akin to Medicare’s Program of All-Inclusive Care for the Elderly program. This approach involves providing a wide range of services to address health and social needs, with an interdisciplinary care team to coordinate care and engagement with community resources. Another real-world example of this approach is the UPMC Community HealthChoices, a Medicaid plan that coordinates both medical care and long-term services and supports. The program also includes pathways to employment, such as resume assistance and interview preparation, further emphasizing the holistic approach to care.”
The article’s authors believe that “A comprehensive approach to improving health could be achieved through all-inclusive services, akin to Medicare’s Program of All-Inclusive Care for the Elderly program. This approach involves providing a wide range of services to address health and social needs, with an interdisciplinary care team to coordinate care and engagement with community resources. Another real-world example of this approach is the UPMC Community HealthChoices, a Medicaid plan that coordinates both medical care and long-term services and supports. The program also includes pathways to employment, such as resume assistance and interview preparation, further emphasizing the holistic approach to care.”
For such a system to work on a nationwide level, the authors write, “[W]e must first address different funding sources. Aligning benefits, streamlining care coordination, and reducing administrative burdens are crucial steps. CMS’s Financial Alignment Initiative, for instance, was an attempt to form integrated plans in which Medicare and Medicaid services are provided by the same plan for dually eligible beneficiaries, so they do not need to navigate back and forth between Medicare and Medicaid benefits. Secondly, health care and social safety-net resources could further be integrated. States could pay health plans or risk-bearing entities for their service of connecting individuals to state social services such as the Supplemental Nutrition Assistance Program, Special Supplemental Nutrition Program for Women, Infants, and Children, Temporary Assistance for Needy Families, and Section 8 Housing programs. It is crucial to also acknowledge that individuals covered by commercial insurance can also face challenges related to social risks. Finally, to ensure adequate resources and advance health equity, social risks adjustments for payment must be set above current levels for historically disadvantaged groups and account for community-level risks.”
Meanwhile, they note t”hat The Population-based Payment Model Workgroup of the Health Care Payment Learning & Action Network (LAN) recommended the use of “big dot” measures in new payment models; for example, using 30-day mortality instead of aspirin at arrival. They advised that for population-based payment models, future-state measures must be based as much as possible on results that matter to patients (for example, functional status) or the best available intermediate outcomes known to produce these results. Modifying LAN’s overall measure structure, we propose identifying measures assessing a population's whole health and linking those measures to financial incentives.”
After walking the reader through a number of detailed elements in their model, the article’s authors conclude that “Measures tied to payment tend to receive more attention and resources. As long as we continue paying for discrete measures in VBP, we can only expect incremental improvements at best, rather than meaningful improvement in real health outcomes. We recognize that it is an ambitious idea to hold a health care organization accountable for addressing both clinical and social drivers of health, using a holistic measurement approach instead of discrete metrics to evaluate success. Ultimately, what patients value most is a holistic way to stay healthy, and we should be willing to invest in this approach. As the CMS Innovation Center explores new model ideas to address social risks,” they write, “we encourage the Innovation Center to exercise its authority to pilot a VBP model that combines both health care and safety-net resources, and validate a robust health measurement tool that effectively assesses a risk-bearing entity’s ability to improve whole health.”
Sai Ma, Ph.D., MPA, currently is a director of Enterprise Quality Strategy and Management at Elevance Health. Ma has held various roles in government, academia, research organizations, and health insurance companies. She previously served as an evaluation director and led the evaluation of several payment models including the value-based insurance design officer at the Center for Medicare and Medicaid Innovation. Qi Zhou, M.D., is vice president of Enterprise Quality Strategy and Management at Elevance Health. Zhou has more than two decades of leadership in quality performance and health equity improvement at Tufts Health Plan, University of Pittsburgh Medical Center, Blue Cross Blue Shield of Massachusetts, and Blue Cross Blue Shield of North Carolina. He led diverse functional teams and developed health outcomes and equity-focused performance measurement systems to support value-based care, population health, patient safety, star ratings, and business growth. Shantanu Agrawal, M.D., MPhil, is a board-certified emergency medicine physician who has worked in both academic and community settings. He is currently chief health officer at Elevance Health. Previously, Dr. Agrawal served as president and CEO of the National Quality Forum, deputy administrator for the Centers for Medicare and Medicaid Services, and director of one of its largest centers, the Center for Program Integrity.
