Promote provider clinical transformation to foster VBP success

Success in VBP arrangements is shown by improving quality for patients, cost-effectiveness for payers, and both patient and provider experiences. Being paid based on value, as opposed to volume, presents providers with flexibility to care for patients with a team-based approach.

To maximize this flexibility and be successful under VBP, you may want to institute or encourage certain operational capabilities such as:

  • Open access, allowing for same-day scheduling of patients;
  • Ability to accommodate patient appointments or phone calls after-hours and on weekends;
  • Meeting patient response and/or scheduling time standards;
  • Sufficient processes for obtaining release of medical histories to and from behavioral health (BH) providers; and
  • Adequate behavioral health support to promote BH integration, (such as through contracted mental health and substance use services, or qualified behavioral health care managers).

Like primary care practices across the country, West Hills Healthcare was hit hard at the beginning of the pandemic. To respond to the challenge, the clinic created protocols for care that were so successful the management team realized protocols could be created for basically everything. These protocols facilitated implementation of operational changes that support VBP success. One example is the training and support of medical assistants to run the annual well visit schedule and work at the top of their license. Implementation of this new protocol allowed the clinic to get patients in for well visits even when provider schedules were full with COVID-19 related care.

The metrics team, including an EHR super user, regularly conducts a deep dive into their EHR to set clinical focus areas, runs lists to identify patients who need to be seen and communicates the right place for documentation. The team prioritizes making it easy to improve care, such as creating a pop-up in the EHR for every patient with diabetes that providers and front desk staff see.

Adding a behavioral health provider and a care manager was another operational change to support success in VBP arrangements. Yamhill Community Care Organization, the local Medicaid payer, recognized the importance of integrated behavioral health to improving care for members and supported West Hills Healthcare with resources to provide these services. This investment grew when the clinic joined CPC+.

More advanced VBP models offer providers more predictable and flexible financial arrangements to support and maintain systemic changes in how care is delivered. For example, moving from a Category 2C Pay for Performance model to one with shared upside (and then downside) risk offers provider entities the greatest opportunity to truly invest in and transform delivery of care. Advanced VBP models more significantly re-structure payment for provider entities to better enable and support delivery system transformation.

Participating in Portland Coordinated Care Association, an independent practice association (IPA) with over 140 primary care providers and specialists, has been instrumental for Northwest Primary Care in partnering with payers, who share the same quality and utilization goals, in contracting around VBP arrangements. The IPA negotiated an LAN 2C pay for performance arrangement with one large payer focused on increasing quality to reduce ER visits, hospital admissions and readmissions. This payment model was built on the 10 year-long Center for Medicaid and Medicare Services Comprehensive Primary Care Initiative and Comprehensive Primary Care + programs which ended in 2021, supporting the clinic to hire and retain care coordinators, case managers, clinical pharmacist and quality improvement specialists hired during this time. These team members, extensive data analysis to identify patients and services needed, and focused outreach to patients resulted in achievement of quality goals and cost savings for payers.

After successfully implementing the 2C model the IPA members felt ready to take on a more advanced VBP model. The IPA and payer negotiated an LAN 3A shared savings arrangement with total cost of care (TCOC). For Northwest Primary Care the engagement of a multispecialty clinic in the VBP arrangement and partnering with payers who understand the value quality groups bring to their patients is key to success.

“With primary care and specialty care providers in the VBP arrangement everyone is on the same page and focused on the best care for each patient.” 
Charlotte Flood, MHA, CMPE
Chief Executive Officer
NW Primary Care Group PC

To be successful with VBP provider entities need internal staff dedicated to transformation, and may benefit from engaging outside expertise for transformation and quality improvement. Identify clinicians and operational staff that understand and can explain best practices around performance and prioritize specific opportunities for improvement in a VBP context. Provider entities and clinicians may need support on how to:

  • Develop, review and interpret reports in a VBP context.
  • Prioritize and track opportunities for performance improvement.

Many provider entities and clinicians will benefit from consultative support early on to learn how to operate effectively under a VBP arrangement. Provider entities can find valued partners from payer and provider associations or consultants, who might offer provider entities hands-on support delivered to individual provider organizations or in a group setting with regular meetings to discuss trends and suggest potential action steps.

Some payers may offer training programs for their network providers to learn the skills for success in value-based payment. Training programs can range from care management webinars to leadership development strategies.

CareOregon has established a Technical Assistance team that consists of staff skilled EHR usage, nurse care managers, and other support staff, the TA Team can assist practices in everything from coaching nurse care managers on caseload volume, to assisting providers in outreach telephone calls to patients.