Value-Based Care Implementation Requires Investments, Collaboration

Prioritizing the shift to value-based care has been at the forefront of the healthcare industry. But the road to transitioning from fee-for-service to value-based payment models is not always smooth.

Convincing payers of value-based care’s feasibility is no longer the issue. The problem lies in the fact that basic healthcare operations do not support value-based care models, according to Patrick Gordon, chief executive officer of Rocky Mountain Health Plans (RMHP) in Colorado.

“The case has been made; payers understand what this can produce. We certainly do when we look at our value-based programs and networks,” Gordon told HealthPayerIntelligence. “It’s just a very heavy lift to overcome decades of optimization of a fee-for-service model to something that’s fundamentally different.”

RMHP, a UnitedHealthcare company that serves Medicaid and Medicare Advantage beneficiaries, focuses on promoting value-based payment models, especially in rural areas. The health plan began its value-based care journey over ten years ago.

“We realized, with the opportunity to expand Medicaid coverage and also to expand coverage in the individual marketplace, that we needed payment models that promote capacity in an already stretched network, particularly around primary care which is the foundation of any healthcare system and the foundation of population health,” Gordon said.  

The payer started by centering on integrating behavioral health into clinical settings.

“The primary focus has been three parts: primary care, ACO clinical integration with some degree of comprehensive accountability and risk, and then behavioral health models,” he explained.

The next step was refining factors like assignment and attribution, risk adjustment, and resources for whole-person primary healthcare.

Value-based care is a collaborative effort requiring investment and engagement from payers and providers. Deciding to implement value-based models is only the first—and perhaps the simplest—step of the journey.

“Health plan organizations are very complex. They’re often very siloed but specialized: one group does one little piece of the puzzle and another does another,” Gordon stated. “Breaking through those silos and working on a cross-functional basis operationally with teams is essential to getting this off the ground. You can’t just work on one little piece and then throw it over the wall. That’s the hard part about it.”

Payers must consider what resources, data, technical assistance, and other infrastructures are necessary to improve capacity and competencies, Gordon shared.

RMHP has seen value-based payment success by making upfront investments and monitoring health plan performance.

“If we were failing at the top level, it would be clear that the stuff we’re doing at the foundation level is not working,” he explained. “That’s not so. Fortunately, we’ve been successful across the board in everything from our individual business to Medicaid.”

It’s important to avoid focusing on just one variable and the outcomes it produces, according to Gordon.

“When you bring a comprehensive set of supports where you have behavioral health, care coordination, data access, technology, support through health information exchange and clinical integration, and aligned quality measures, when you bring all of that together, that’s when you see results.”

Getting providers on board is also a key requirement for value-based care. Providers who have embraced advanced value-based care competencies are more likely to increase the number of complex populations they serve, Gordon noted.

This is especially important as value-based models can help address health equity.

“The people who most need support in BIPOC communities, in rural communities, in underrepresented communities, often have the lowest fee schedule support through programs like Medicaid,” Gordon said. “So, it’s fundamental that we do something different to change that paradigm.”

Healthcare providers in Colorado have been responsive to RMHP’s value-based efforts, partly due to the recognition that these models can improve affordability and partly due to public policy.

“What’s different now than ten years ago in a place like Colorado is that there is public policy support,” Gordon pointed out. “[There is] pretty significant public policy focus on the development of alternative payment models, both within the commercial and individual markets, which are regulated by the Colorado Division of Insurance, as well as the Medicaid space, where the Medicaid agency is deeply engaged in this effort now.”

Colorado has assembled primary care learning and leadership collaboratives that include payers, providers, and consumers to help further value-based care. The state has also implemented contractual, regulatory, and statuary requirements for payers to meet regarding alternative payment models.

“Frankly, that generates a lot of controversy because it’s public policy that’s driving part of the change, but it also generates a lot of understanding that investment is required and change is required because if we don’t, we won’t comply. Or maybe we will comply minimally, but we’ll lose our position in these programs and in the market,” Gordon indicated.

Given the many moving parts required for value-based care success, Gordon praised the support from community leadership, UnitedHealthcare, and public policy.

“We don’t always agree with our regulators about the how, but we are in agreement about the what,” he mentioned. “That makes all the difference in the world.”

“We have what we need. We have the flexibility, the latitude, and the direction to carry out what we need to carry out on the ground. And when those things come together, a lot of progress can be made. The environment and the connection to community is a big factor in the success,” Gordon concluded.