Over the last decade has been a huge trend in healthcare with the predominance of value-based care programs.  Using quality measures as a way to quantitatively and qualitatively measure and evaluate how well clinicians are performing their jobs, these measures can impact payments to the physicians and/or their employer health system.  Payers, from Medicare to commercial insurance companies use value-based contracts to incentivize behavior.  So, value-based contracts are agreements between healthcare providers, payers (such as insurance companies) that tie the payment or reimbursement for healthcare services to the outcomes they deliver rather than the volume of services provided. The goal is to improve healthcare quality and efficiency while controlling costs by shifting the focus from quantity to quality.  This is a marked difference from the traditional fee-for-service model, where healthcare providers are paid based on the number of services they deliver, regardless of patient outcomes. However, with value-based contracts, payment is linked to achieving specific health outcomes, such as improved patient health, reduced hospital readmissions, or better management of chronic conditions.  But how many quality measures on average does a primary care provider (PCP) need to track and meet, on average, based on payer contracts?  A new study, perhaps the first of its kind, helps us answer this question, and the answer is not good for the PCPs, or the patients.

Claire Boone, PhD, a health economist along with Ari Robicsek, MD chief analytics and research officer for the Providence Research Network and colleagues  from University of Chicago, Booth School of Business report on study findings with a serious message for the U.S. healthcare system’s penchant for value-based care arrangement—too much! 

Background

With results of this analysis of value-based care published in JAMA Health Forum the Providence Health Research-led study team found that based on the analysis occurring in one large integrated health system primary care physicians (PCPs) needed to track 57 different quality measures across myriad payers, all of which are tied to actually getting the providers’ employer paid via value-based contracts.

Step  back and think about the implications.  On average physicians are required to be mindful of and track 57 differing quality measures! Yet how could that be possible?  Would this not create a complex, disjointed and cumbersome environment for physicians, nurses and the staff charged with caring for patients?  But this is exactly what the researchers found.

What payer type required the most quality outcomes measures?  Medicare, under Centers for Medicare and Medicaid Services as part of Health and Human Services (HHS) covers the insurance for 67.4 million people in America as of August 30, 2024.

PCPs on average must track 13.42 measures for Medicare, with 10.07 measures on average for commercial payer contracts, and 5.37 for Medicaid contracts.

A novel analysis covered 890 primary care physicians from 2020 to 2022.   Boone, Robicsek  and colleagues’ work demonstrates the possibility of a broken system when they document:

“Value-based contracting is intended to incentivize care improvement, but it is unlikely a clinician or practice can reasonably optimize against 50 or more measures at a time. Increased use of such levers may also carry unintended consequences. Clarity and salience are crucial to changing behavior, and the burden of extraneous information and processes has been increasingly associated with adverse outcomes, such as physician burnout. As payers increasingly shift toward value-based contracts, additional research is needed to understand how their ubiquity affects their benefits and how such contracts can be scaled sustainably for clinical care.”

Findings

The subject of this study, a large integrated health network employed 890 physicians (58.3% women, 41.7% men) on the West Coast. TrialSite notes that several of the researchers for this study work for Providence Health System, based in Renton, Washington, a not-for-profit Catholic healthcare system with 51 hospitals, more than 800 non-acute facilities, and numerous assisted living facilities in the western half of the United States with large presence in Alaska, Washington, Oregon, California, Montana and a few other states. Providence Health & Services was founded by the Sisters of Providence in 1859 and merged with St. Joseph Health in 2016.

With a physician caring for an average of 1,309 patients in this subject system, the PCPs
on average participated in 11.18 value-based contracts (commercial insurers, 49.50%; Medicaid, 21.49%; and Medicare, 29.01%). And the trend is toward more value-based contracts, and hence all things being equal more complexity.  Such contracts grew from 9.39 in 2020 to 12.26 in 2022. The authors reveal that they could not obtain quality measure data for 29% of contracts.

So how were unique quality measures defined?  The quality measures were deemed unique if they referenced different conditions. Ideally of course payers would at least try to standardize value-based payment measures. But clearly at least from the output of this study this does not seem to be the case.

In an interview with MDEdge first author Boone shared that she expected payers to coordinate quality measures, but that they do not.

“The fact that they largely are not really the main finding of this paper. Without coordination, the use of value-based contracts and quality measures at scale leads to many unique measures being used. This may reflect the fact that there are so many important tasks to do in primary care, and there’s no consensus on which ones should be included in quality-based contracts.”

Review of Value-based Contracts

Some key attributes of value-based contracts include several concepts that need to be better understood for context.

Outcome-based payments remain front and central in value-based payments. And those 57 distinct quality measures that the average PCP must track become tied ultimately to payments. That is, payment or reimbursement depends on these predefined health outcomes. In the context of medical services if the service delivers the expected results, the provider receives full payment. If not, payment may be reduced or refunded.

The reduction in pay, or even refund associates with a key concept in value-based contracting: risk sharing. Value-based contracts often involve some level of risk sharing.

But cost effectiveness emerged as another concept in value-based contracts. Meaning these contracts aim to ensure that healthcare spending delivers value, with a focus on long-term benefits, such as reducing the need for future expensive treatments by improving patient health early on.

TrialSite suggests however, with the explosion of myriad value-based contracts Americans health in the aggregate has seemingly declined, and this important study published in JAMA Health Forum may hold the key why.

Importantly often a complaint of PCPs is the need to constantly enter data into electronic health records. This is because robust data collection and patient monitoring emerged as crucial to track the effectiveness of medical services, necessary to determine whether agreed upon (contacted) outcomes have been met.

It’s important to note that value-based contracts are  becoming more common as healthcare systems move toward models that reward better health outcomes and cost control. Based on this study we find that this means on average PCPs must track in the case of this unidentified West Coast integrated health system 57 differing quality measures.  And we wonder why physician, nursing and staff burnout becomes a topic?

Lead Research/Investigator

• Claire Boone, PhD,  Booth School of Business, University of Chicago; Providence Research Network; Corresponding Author
• Anna Zink, PhD,  Booth School of Business, University of Chicago
• Bill J. Wright, PhD, Providence Research Network
• Ari Robicsek, MD Providence Research Network

Source: JAMA Health Forum