Enterprise and API

High-quality primary care is a crucial component of a sustainable, affordable, and high-functioning healthcare system. Its success is well-documented, especially in peer nations, and yet the economics of healthcare remain dominated by a transactional payment model known as fee-for-service. This approach has weakened primary care and rendered it both less effective and less accessible. Complex, hypertrophic administrative infrastructures have been developed to support this payment model, in many cases costing more than the care delivery itself. Health technology has followed suit, intentionally designed around the documentation and billing needs of this model in order to translate individual clinical transactions into maximum reimbursement. 

There is good news, though: the way we pay for healthcare is beginning to change. Incremental shifts toward alternative payment models (APMs) take the focus off of volume-based metrics we see in traditional fee-for-service reimbursement in an attempt to migrate the U.S. healthcare system to one that delivers better value for consumers and payers, commonly known as value-based care (VBC). Alternative payment models vary and fall on a spectrum, all of which still contain some component of fee-for-service incentives, except for the most advanced APMs which focus on population-based payments. As APMs continue to become more prevalent, there appears to be growing momentum behind the fact that healthy primary care systems create more wellness, and more wellness creates better health outcomes with lower costs of care. 

Primary Care Delivers More Value, But APMs Aren’t Helping Them…Yet.

If you follow the evidence, it’s clear that primary care holds the key to better value in healthcare, making it the well-earned focus of most new payment models.

For example, in many APMs today, practices are paid incentives for their performance on certain quality measures, for identifying and reporting (to the payer) specific conditions which can be used to risk-stratify populations, and for providing specific services tied to better health outcomes. 

However, current APMs have unintentionally become the source of yet another variable independent primary care practices need to manage in an already overwhelmed, under-resourced, and turbulent primary care system. Even worse, these payment models are continuing to evolve at a dizzying pace, demanding new competencies and driving additional reporting requirements. The supplementary workload often is unbearable, and many practices opt out of the additional headaches, calling into question whether these APMs are truly creating better value. 

How to Make VBC Work Without Torturing Primary Care Physicians

Although the health technology industry has recently rushed to offer “value-based” solutions aimed at enabling success in APMs, the majority of these solutions target a single problem set and are not integrated into the point-of-care workflow. The resulting fragmentation can feel to the primary care team like a chaotic experiment, with various platforms, multiple login credentials, segregation of patient information, and duplication of documentation. A few electronic health record (EHR) vendors have set out to evolve their native capabilities within a single platform, but this too proves problematic. At the root of the problem lies how many solutions are needed, how little we know about the best way to design these solutions, and the urgency in the primary care sector to provide the solutions.

If the healthcare dollars are migrating towards value-based payment arrangements, how can the health technology industry play a meaningful role in restoring our struggling primary care system to its powerful role in healthcare and help drive success in alternative payment models? 

One of the ways we’re approaching this at Elation is to focus exclusively on helping primary care leaders deliver better care. Central to this is our work to seamlessly embed value-based contract requirements within the natural clinical workflow and assist with coding based on documentation already being captured in the encounter notes. The impact to clinicians is that it drops the cognitive and administrative burden while driving success—by design. 

As an example, let’s look at how this focus impacted a physician organization with 250 PCPs serving an aging, urban population facing challenges with its Medicare Advantage provider network. The organization was under-performing on HEDIS and Care for Older Adults (COA) measures, and under-documenting chronic conditions using hierarchical condition codes (HCC). 

Using Elation, PCPs experienced:

• An increased awareness of care gaps (HEDIS and COA) and HCC codes through real-time reminders delivered elegantly within the natural clinical workflow. 

• Automatic coding for services already being provided.

• Efficient templates to help guide the workflow and documentation. 

• Alerts/reminders of previous and suspect chronic conditions to be assessed. 

As a result, this physician organization realized:

• A 200% improvement in care gaps closure within 1 year. 

• A 19% increase in HCC coding.

• A recapture of $2,208 more per patient than PCPs in this same group using other EHR platforms.

VBC through APMs is the future, but it shouldn’t hurt the very clinicians and patients it is trying to help. By realizing that primary care is intrinsically tied to the success of VBC, healthcare technology leaders can do a better job of making sure that VBC-focused innovations are tailored to primary care’s unique needs. Without this consideration, payers and patients may never realize the full potential of what VBC delivered through APMs can do.

Sara J. Pastoor, MD, MHA is Elation's Director of Primary Care Advancement and leader in primary care advocacy. Dr. Pastoor is a board certified and clinically active family medicine physician. Her experience as a primary care innovator spans a career in military medicine, academic medicine, private practice, and employer-sponsored delivery models. She received her MD from Rosalind Franklin University of Health Sciences and MHA from Trinity University.