Tom Sullivan | May 24, 2022
While the Centers for Medicare and Medicaid Services has essentially led the way toward value-based care and testing new models, the private sector has largely followed the path paved by CMS. But as the industry looks beyond the ongoing pandemic and CEOs lead efforts to emerge with a more resilient, equitable and affordable health care system, the time has come for that to change.
“We’re in a moment in time where there is urgency for the commercial market and private sector to really step up and accelerate, to do more and do better,” said Brian D. Pieninck, President & CEO, CareFirst BlueCross BlueShield. “The first 10-year phase of advocating for the shift from volume to value emphasized the importance of thinking about how we move in a more consistent direction that leads to better health outcomes across public and private payers.”
At the 2022 Health Evolution Summit, Pieninck participated in the Main Stage discussion, Payer Insights: The Next Era in Value-based Care. Moderated by Justin Roth, Head of Investment Banking at TripleTree, the discussion also included Dan Mendelson, CEO of Morgan Health and Liz Fowler, PhD, Deputy Administrator and Director, Center for Medicare and Medicaid Innovation (CMMI).
“We’ve learned a lot from the Medicare experience,” Mendelson said. “Now it’s really a matter of raising expectations to accelerate progress over the coming decade.”
Payer alignment needed
Looking toward the future, the discussants noted that payers working together will be critical to the future of value-based care.
“We simply cannot make value-based care work fully unless we get the commercial payers on board. Medicare can pave the way, but we can’t do it alone,” Fowler said. “We really need those partnerships. We need a willingness for payers to work with CMS and each other.”
To enable such partnerships, Pieninck suggested the industry work toward more data-driven decision making, noting quality metrics, data exchange and interpretation of the data to become the standard to benefit payers, providers and patients. Such standardization would also drive more meaningful systemic change. Fowler called for an increased push toward accountable care and greater coordination with an emphasis on primary care in the short-term.
“We need to collectively align to make value-based care more turnkey for those organizations and people that have to adopt the change,” Roth added.
Achieving that will, of course, require working with health systems and providers.
Health system engagement
As powerful as CMS is and even with so much influence the agency will have over value-based care in the next 10 years, working with payers can only accomplish so much.
“It’s not just about aligning payers,” Fowler said. “We also need cooperation on the ground from providers and a willingness for providers to work with us.”
Pieninck said that he sees more providers that are willing and receptive to work with payers to move toward value-based care.
“This is a question of execution and whether we are willing to do some things, individually and collectively, very differently than we have in the past to leverage this opportunity to transform health care,” Pieninck said.
The discussants noted that engaging with providers can begin with ensuring they recognize the benefits, such as the ability to work smarter using different practices that improve efficiencies.
Mendelson pointed out that the pandemic instilled a sense of urgency in everyone by accelerating the core components of value-based payments, accountable care and population health.
“We need to be providing a different level of transformational care in order to keep people healthy and engaged,” Mendelson said. “We need to be able to motivate providers financially to make all these great models within the Medicare program work across the commercial market for employers and employees.”
The long journey ahead
Ultimately, health plans, health systems and CMS all need to be on the same page about value-based care. Otherwise, too many organizations will continue to have what Fowler described as “the foot in two canoes problem” with too many patients remaining under fee for service for value-based models to succeed.
“Transitioning to value is a marathon and not a sprint. The impact is maybe greater than the numbers suggest, but we are going to be at this for a while.” Fowler said.
Roth added: “This is a journey that we are going to be a part of for the rest of our careers — and certainly for those who will come after us.”