It is often difficult to get physicians and health plans to be on the same page, but a new AMA resource on value-based care (VBC) payment methodologies manages to capture this alignment on each of its 74 pages. It is a resource that health systems such as Geisinger and The Permanente Medical Group have helped with.
The document, “Creating a Sustainable Future for Value-Based Care: A Playbook of Voluntary Best Practices for VBC Payment Arrangements,” (PDF) offers voluntary best practices for overcoming key challenges associated with underlying payment methodologies for value-based care arrangements.
It builds on prior work that was focused on improving the collection and bidirectional data sharing within these arrangements, and both of these playbooks are part of the “Future of Value” collaboration with the health insurer trade group AHIP and the National Association of Accountable Care Organizations (NAACOS) to advance sustainable value-based care adoption.
“We understand that the amount of burden of complying with all the various models across numerous payers is a significant barrier to excellence and implementation and success in these models,” said Carol Vargo, the AMA’s vice president for practice sustainability, during a program sponsored by the AMA Integrated Physician Practice Section (AMA-IPPS) that was held as part of the 2024 AMA Annual Meeting in Chicago.
The effort works to “cut through some of the noise” between health plans, health systems and physicians to find how issues that have perennially stifled advancement of value-based care models can be overcome, she said.
Stephen Parodi, MD, vice chair of AMA-IPPS and executive vice president of The Permanente Medical Group, said the work group meetings between the parties where the playbooks were developed were nonadversarial.
“I was impressed that the members of AHIP do recognize the stresses that our practices are under,” said Dr. Parodi, who is also the executive vice president of The Permanente Federation.
He added that the health plans also acknowledged issues stemming from delivering care in rural or historically under-resourced communities and the impact social determinants of health can have on patient well-being.
“To hear plans—in addition to physicians—actually talking about that was encouraging,” Dr. Parodi said.
Moderating the panel was AMA-IPPS Chair Adnan Munkarah, MD, care delivery system president and chief clinical officer at Henry Ford Health, who described the work group meetings as “fun” even though discussion on topics such as patient attribution could go on for hours.
It was also noted, however, that there was no discussion around payment strategy or payment levels and that an antitrust attorney was present to ensure avoidance of areas of questionable legality relating to the Stark Law or anti-kickback statutes.
Also on the program panel was Narayana Murali, MD, chief medical officer of medicine services at Geisinger and immediate past chair of AMA-IPPS.
“It was a power-packed group,” said Dr. Murali. “Getting all of us aligned to identify where we intersect was not an easy task—so hats off and kudos to the AMA for this effort."
Drs. Murali, Munkarah and Parodi—along with Francis Mercado, MD, the ambulatory associate chief medical officer for Virginia Mason Franciscan Health’s Franciscan Medical Group—served on the work group that developed the playbook.
Geisinger, Henry Ford Health, The Permanente Medical Group and Virginia Mason Franciscan Health are members of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
Everything is negotiable
The revelation that came out of the work group meetings was that “all of this stuff is negotiable,” Dr. Parodi said.
“It is important that, as physicians, as leaders of groups—whether you're small, solo, large group, or big system—all of this comes into play in terms of what you're accountable for, how much you're accountable for, when you're accountable, and when you're going to get paid,” he said. “This playbook provides a road map for how to think about it.”
It was noted that while the playbook helps identify best practices in attribution for primary care practices in value-based care arrangements, calculating attribution for specialty practices is still a work in progress and is an area ripe for future focus.
“Depending on where you are in your growth trajectory as a value-based care organization, you’ll have issues related to people—the administrative staff to do the work—as well as the support structure and where you are talking about workflows and your ability to manage care coordination,” said Dr. Murali.
He added that this includes information technology related to digital dashboards and analytics.
A practice’s risk level, accountability and financial incentives will depend on where they are on the value-based care growth curve and how much support they need in making infrastructure investments, Dr. Murali explained.
“We had a lot of discussion about the tiers of financial incentives,” he said. “How do you stimulate somebody to go into value-based care? And how do you incentivize them and create a glide path as they go through the programs?”
The need for value-based care contracts to have a stop-loss provision was mentioned.
“All these health plans have global stop-loss coverage,” Dr. Murali said. “When things become extremely to the detriment of a health plan, the health plan has mechanisms to prevent it from going belly up.”
Physician practices and health systems need the same mechanisms, he said.
Dr. Parodi echoed the importance of getting advance payment from health plan value-based care partners—to both cover the investment in needed infrastructure and to balance the risk involved in transferring patients from fee for service to a value-based model.
He also stressed the need when negotiating to avoid basing revenue projections on a single year.
“You want to look at multiple years because you can have variability—and, by the way, we had one big, massive variable called the COVID-19 pandemic,” Dr. Parodi said.
Dr. Murali had praise for the playbook’s authors who were able to concisely explain complicated topics.
“Obviously, the whole attribution discussion is pretty complex, but the details are well outlined in the document,” he said. “I think they've done a spectacular job.”
The need for this effort to continue was noted by Dr. Murali.
“We need to get health care costs down for our patients while concomitantly improving health outcomes and patient experience with all of us, physicians, payers, hospitals, and clinician care teams,” he said. “If we can't get together and convene and address our points of intersection, we are not going to make progress. “That's what this body can do. And that's where AMA can help us with that process.”
