Value-Based Care in Diabetes Care Management Calls for Policy Changes

Chronic disease management in diabetes may benefit slightly from value-based care and alternative payment models, but the results will not be substantial until certain policy changes take place, according to a commentary published in Health Affairs.

The researchers first examined thirteen studies of alternative payment models, categorizing them based on the financial risk for the providers. Category one represented the lowest risk and category four represented full risk.

Pay-for-performance models were in category two and represented five of the studies. The studies produced mixed results on whether bonus payments and diabetes process quality measures positively or negatively influenced each other. While some studies saw an uptick in the quality measure that was under analysis upon implementation of bonus payments, other studies cited decreased quality measure uptake.

The five shared-savings and shared-risk models—which are considered category three—showed improvements in certain tests related to diabetes.

The researchers also looked at three population-based payment models, which fall under category four, including Blue Cross Blue Shield of Massachusetts’s value-based contract Alternative Quality Contract. Each of the three models reported positive results, some more significant than others.

The researchers also assessed eleven value-based insurance design programs, specifically ones designed to address diabetes medication management. 

Some studies found that value-based insurance design led to slightly higher medication adherence. 

However, achieving positive results in value-based care interventions for diabetes management could depend on the patient population. For instance, patients who started the intervention with very low adherence, low-income patients, or Medicare beneficiaries with higher cardiovascular risk might see stronger results from a value-based insurance design.

One study found that emergency department visits dropped 16 percent due to the implementation of a “zero-dollar preventive drug list.”

A large study of 32 value-based care plans found that targeting high-risk patients, offering wellness programming, and incentivizing mail-order pharmacies with lower copays were a couple of strategies that positively influenced medication adherence.

“Models that place greater financial risk on providers, such as global payment and shared savings, tend to demonstrate greater improvements in diabetes quality metrics compared with lower-risk pay-for-performance models,” the researchers explained. 

“This pattern is consistent with expectations that higher-risk models incentivize providers to make larger investments in program components. However, nearly all of the payment models we looked at assessed process measures alone, and improvements in these processes might not translate into improvements in outcomes.”

The researchers cited challenges such as attempting to transition providers into new payment models with new workflows and changes in care practices, all while managing multiple other alternative payment models with different requirements.

As a result, some providers may be hesitant to enter into alternative payment models. Integrated health systems may be best equipped to manage these changes and layers of contracts.

The minor successes that value-based care has seen with measures like medication adherence coupled with the lack of serious impact on outcome measures may point to the fact that medication adherence is only part of the solution. It requires supporting strategies to help members with diabetes pursue chronic disease management.

The researchers noted that alternative payment models can add to the healthcare system’s fragmentation without policy changes. They suggested testing out alternative payment models and value-based insurance design models in Medicaid, standardizing quality measures for diabetes care across alternative payment models, and implementing alternative payment models and value-based insurance design through a single payment model.