North Carolina Stakeholders Work to Simplify Value-Based Primary Care
During an April Primary Care Collaborative webinar, stakeholders in North Carolina’s healthcare transformation effort discussed how the state is trying to reduce the administrative burdens making it difficult for primary care practices to transition to alternative payment models.
The North Carolina State Transformation Collaborative, or STC, is part of a broader public/private initiative of the Healthcare Payment Learning and Action Network and the Centers for Medicare and Medicaid Services, explained Rebecca Whitaker, a research director with the Duke Margolis Institute for Health Policy. It is designed to promote value-based and whole-person care through multi-stakeholder partnerships. In addition to North Carolina, there are three other states participating in this initiative: Arkansas, California and Colorado.
North Carolina is recognized as a leading national model for how to shift from paying for healthcare services to investing in health. Over the past few years, the state has implemented Medicaid managed care and Medicaid transformation, with an emphasis on whole-person care. The state’s Healthy Opportunities Pilots are using Medicaid dollars to address drivers of health. “And we see similar investments in value-based care and whole-person care in the commercial context in our state as well,” she said.
Whitaker said multi-stakeholder alignment on the components of payment models like performance measurement and data sharing can make it easier for provider organizations to adopt value-based payment arrangements, “but it's certainly challenging to get to agreement on some of those practical steps to achieve multi-stakeholder alignment, especially when stakeholders have approaches for how they achieve their own organizational goals,” she said. The North Carolina STC was launched in February of 2023 to identify strategies that could support North Carolina-based investments and encourage collaboration across stakeholders that may not typically interact.
A few healthcare leaders who have participated in STC meetings spoke about the value of collaboration between payers and providers.
Tom Wroth, M.D., is president and CEO of Community Care of North Carolina. CCNC supports the primary care delivery system by providing practice support and care management services using targeted analytics and innovative practice-based tools. He spoke about how incredibly rare it is to convene CMS leadership, state leadership, health plan leadership across multiple payers, and provider leadership. “We represent a lot of independent practices across the state,” he said. “In fact, 450 independent practices, big and small, with all sorts of different capabilities, and they're really getting crushed by the administrative complexity of multiple programs,” he added. “So it was an opportunity to really work on measure alignment and what we can do as sort of a public utility to help all of these practices reduce some of the administrative complexity and get folks back to what we want, which is practice transformation and improved health outcomes for patients.
Greg Moon, vice president of healthcare strategy planning and performance at Blue Cross Blue Shield of North Carolina, said the collaborative is really helping the state align around model design, around key enablers and technologies and what data sets they need to succeed. "The reason that we joined is that we wanted to be part of the ecosystem discussion. This is a set of ecosystem problems that we're facing, and we need ecosystem solutions,” he added.
The thing that gets lost in the conversation about value-based care, he said, is that we usually are talking about the blocking and tackling to make the program go, but it is really a paradigm shift that establishes a collaborative approach to these problems. “If we didn't have value-based care, we would be left with payers and providers arguing about fee schedules and managed care processes, etc.," Moon added. “So philosophically, that's why we wanted to join. Tactically, just having an ear to the ground to what everybody is thinking is incredibly valuable. We can be kind of navel-gazing in our own world. We have our models. We're working with our given set of providers in the network. But it might not occur to us that these providers have multi-dimensional relationships around value, and they have variation across that. In the early days of being part of the collaborative, we heard that the quality measures were wildly variable. You could just think of the added administrative burden from that. So just the insights we get from the group are very, very valuable.”
Whitaker said the STC’s work has been guided by a multi-payer framework that some of her colleagues at Duke Margolis put out several years ago. A key part of that is identifying shared goals to make progress, motivate support, and allow for implementation and evaluation. The specific goals identified were addressing health disparities, improving population health, reducing healthcare costs, relieving provider burden and enhancing the patient experience. “These are broader than just lowering administrative burden, but I think the goals are really inter-related and mutually reinforcing,” she added. “Certainly addressing health disparities also means ensuring sustainability of small, rural and underserved practices as well. So these things go hand in hand.”
Wroth said that for his provider group, the low-hanging fruit is around measure alignment and simplifying the reporting mechanism. “We've got value-based contracts across four or five different Medicaid managed care plans, Medicare Advantage, Medicare Blue Cross/Blue Shield, with Greg's organization. So we've got multiple measure sets, multiple reporting schedules. For small practices, we're still on lots of different electronic health records. We actually have 52 different electronic health records. So by hook or by crook, we pull out A1Cs, blood pressures and colon cancer screening, pap smears and report to the various payers. This is not even what's happening in the workflow of the practice, but just as you know, primary care enabler or clinically integrated network, what we do to report,” he explained. “We were hoping, with all the players at the table, to really try to get to some measure alignment and agreement on the key measures across multiple plans.”
He said in meetings of the collaborative, the Secretary of Health and Human Services for North Carolina was there and basically laid down the gauntlet, and said don't come out of the room until you all agree and can move this forward. “That leadership was really critical in the process,” Wroth said.
Moon said payers are trying to understand how to make sure these models are sustainable, feasible and administratively as low burden as possible. “The collaborative was a great channel for understanding those needs,” he said. “We also have a lot of one-on-one interactions with our providers within value arrangements. We have a team dedicated to meeting with folks going over the reporting, looking for opportunities. But it's a two-way street where we definitely hear the pain points that come through from this. That's actually what led to us from what we call our Blue Premier 1.0 model to our blue premier 2.0 model, which was really predicated, in large part, on the feedback that we got from providers. So I think the most important way is keeping our ears to the ground and having dialog around these things and constantly looking for opportunities to make these things more palatable, sustainable and feasible.”
