We revisit an earlier episode with Yates Lennon, MD, President of CHESS Health Solutions who who provides a concise overview of value-based care and questions providers should be asking
Yates Lennon, MD, MMM, currently serves as the President and Chief Transformation Officer for CHESS Health Solutions. He is nationally known for his work in quality, previously serving on the American Medical Group Association (AMGA) Quality Leadership Council and presently on the National Association of Accountable Care Organization’s Quality Committee. Dr. Lennon’s background includes 23 years as a practicing OB/GYN and a Fellow of The American College of Obstetricians and Gynecologists. He served as Chief Quality Officer for Cornerstone Health Care before joining CHESS in 2018 as Chief Transformation Officer. Dr. Lennon assumed the role of President in 2021. He has a deep understanding of practice transformation and how to engage physicians and their staff. His value-based care expertise allows him to translate his knowledge into initiatives that health care teams understand and can implement to ultimately transform patient care.
Let’s start at the very beginning. What is value-based care and why does it matter?
So, what is value-based care. I tend to think about population health and value-based care side by side. And, in some ways, it’s value-based care is population health plus a payment structure that you find in value-based care models to create sustainability for those pop health efforts. So, when you think about population health, you’re thinking about groups of patients, whether that’s groups of patients by demographics, by disease state, by recent hospitalization. They’re all ways you can slice populations. And you’re thinking about caring for that group of patients. Now at the end of the day, population health is delivered one patient at a time, generally speaking, in my mind anyway. But, when you add value-based care to it, you’re creating an incentive structure that creates sustainability so that you can deliver the services you need to care for those populations of patients as they move through the continuum of care. So, from the outpatient setting, to inpatient, to home, to skill nursing facility, back home.
That’s a very broad definition, but when you dive a little bit deeper into value-based care as a clinician, I’m thinking about value-based care as a way to support resources that will assist me in caring for those patients. So, it’s not all falling on the physician or the advanced practice provider at the point of care in the office.
What is the triple aim and how does practicing value-based care help to achieve that?
So, the triple aim was coined back in 2008 and it really aims to do, as you might guess, three things. One, is to improve the patient experience of care. The second is to lower the cost of care. And then the third would be to improve quality or improve the health of populations. Value-based care, and as we discussed already, is perfectly suited to solve these.
So, if I start with improve the patient experience, or patient satisfaction. The fact that a patient is able to access a care team larger than just the provider and the nurse, I think, moves us in that direction. The other aspects of care when you think about, I think about my parents, so, and their encounters with the health care system. And how it’s been traditionally very disjointed. Still is. They live in a part of the state where value-based care is not really penetrated very well. And it’s very disjointed. My Mom gets information from her providers and her payors, and she’s confused. She doesn’t know what’s real, what she should respond to, you know, is this a scam, just all kinds of questions. So being able to reach into a care team on a consistent basis is very important. And especially for that generation. They don’t want to bother their physicians. We could have a discussion about whether that’s the right thing to do or not. But, that’s just the way she thinks. I don’t want to bother anyone. So having a care team whose proactively reaching out to a patient, especially following an important transition, goes a long ways towards bringing comfort and to that patient. And when I hear the stories from our Care Coordination team, including our social worker, the impact their having on patient’s lives is profound. They are addressing things that I as a clinician would never get into in an office visit. In part sometimes because I was afraid to ask the question because I didn’t have any resources to deal with what I figured the answer would be.
To improve the quality or improve the health of populations, so we’re focused on quality, closing care gaps. We’re focused on an Annual Wellness Visit, which is designed to allow a provider to look at a patient’s whole picture. So, where are they receiving care, do they know who their providers are, do they know who their durable and medical equipment providers are. Are they up to date on screening procedures and are they up to date on any disease-specific quality measures that they should have addressed, like hemoglobin A1Cs, or blood pressure under control? Those types of quality measures.
And then finally, lowering the cost. So, I go back to Care Coordination again. Thinking about chronic care management, transitional care management, trying to reduce readmissions. And also to try and prevent unnecessary admissions as you engage with patients in the their the management of their disease states. I think the other thing that value-based care does is it puts the right incentives in place for provider access. When I’m talking to physicians and they ask, you know, what do we need to do, there’s always one answer that you can do tomorrow, and that is improve access. So, the idea that we’re going to be open 8 A.M. to 5 P.M. and shut our phones off at lunch is a bit antiquated. That might be ok for a fee-for-service world, when your schedules full, and that’s the thing that matters most. But, in fee-for-value, if you can provide access to patients when they need it, so that they can receive care for non-emergent conditions in a non-emergent setting, then that saves money for the system and will loop back to the first thing I talked about, and it improves the patient experience of care. I don’t think there’s anyone, very few people if any, that enjoy sitting in the emergency room waiting. And, if you’re condition is not an emergent one, if you don’t have an emergency situation, then you tend to be triaged to the end of the line and you spend more time there in the waiting room, which is not good for patient experience, which is not good for provider experience, which is not good for patient experience ratings for the provider. So, it’s kind of, it gets to be a snowball effect.
And you know, a few years ago, I’m not sure who gets credit for this, but physician burnout we all know is a huge issue and COVID has not done anything but accelerate that problem. And so, someone term the quadruple aim, adding physician or provider experience as the fourth arm of the quadruple aim. And we’ve already touched on this a good bit, but from a physician’s standpoint, value-based care aims to implement team-based care. So, they’re not the same, but they go hand-in-hand. In team-based care, the purpose, the aim there is to be sure that everyone on a provider’s team, those people in the office, those people behind the scenes who may be in a hub somewhere or perhaps embedded in their physical facility in a room where they’re not focused on the patients who are coming in and out each day, but those patients who are at home, they’re trying to outreach. All of those people together, working at the top of their license, is what we aim to do in value-based care. For physicians, we would like to see them doing the things that only physicians can do. The things that other people on the team can do, then let’s let them do those things. And let’s use protocols and evidenced-based guidelines to direct care for the 80% of the population, I always laugh and say the 80% of the population that’s read the textbook, and they kind of behave according to the textbook. There’s 20% of the population that don’t. And that’s, you know, the medical background and training that physicians and APPs have. Decision making comes into play there. You can’t necessarily follow an evidence-based guideline for whatever reason. We know that everyone won’t just fall into a nice, neat, little box. So, really putting their decision-making skills, their assessment skills, their diagnostics skills to work in that part of population that won’t fit the rules.
And then, I just learned recently that there is now the quintuple aim, which is adding in health equity. And as I think about what we’re trying to achieve by improving the outcomes of care for all patients by removing barriers that they face and typically those are, you know, social economic barriers. Value-based care is set to address that. When I look at the patient stories and hear the patient stories that come from our care coordination, pharmacy, social work hub, they are constantly working with individual patients to identify barriers to improving their care and ensuring that they have outcomes that are equal to those who are not facing the same barriers. Value-based care is perfectly set up to address each of these stakeholders. When I think about, you know, the medical industry, if you will, in it of itself, but also the providers, the patients, and the folks around them that we would call their care team.
I’ve heard you say that making the move from Fee-for-Service to Fee-for value, aka value-based care requires a new way of thinking. Can you elaborate on this?
Sure, be glad to Thomas. So, I go back to the old fee-for-service world. The world I grew up in. And I still remember asking myself that question the first time I sat through a meeting about value-based care. And, as an OBGYN by training, this was 12 years ago now. I went home after that first meeting and I thought, now what do I do differently tomorrow. And I struggled for a little while to understand the only thing that I could come up with was continue to deliver high-quality care, have access for my patients, and, you know, don’t sent people to the emergency room or labor and delivery unless they need to be there. See them in the office if its possible.
But as I understood the concepts more, I think there are several areas that we can call out and kind of make a comparison between the two worlds. We’ve touched a lot on consumer experience or the patient experience already. So, in the old world, confused, frustrated, you know, not knowing what’s going on. Provider A is not talking to Provider B. Provider A didn’t get the referral letter from Provider B when the patient was sent to the orthopedic surgeon, the cardiovascular surgeon, or the endocrinologist. And communication is just not taking place between providers. So, this leaves patients trying to navigate a very complicated system on their own. In a fee-for-value world, that patient experience should lead one to feel valued and engaged. So, there are resources at play from the care coordination teams, the pharmacy teams, our quality teams, we’re just reaching out, pulling that patient in, and making sure they feel supported throughout their care journey.
From a care delivery standpoint, we’ve always been reactive. So, we’re responding to illness in a fee-for-service world traditionally. Now, there had been progress around preventive medicine and addressing cancer screenings, for instance. Colorectal cancer and breast cancer screening. And a lot of that work has been done and is important, but I wouldn’t say that’s really geared at overall health so much. And, even in the fee-for-service world, we still were largely reactive. In a fee-for-value world, we’re more proactive. So, we’re using data, we’re using our various teams to identify patients. Like I said earlier, not just who are at increased risk today, but who we believe are at risk in the future of some untoward event. Whether that be clinical, or clinical and financial. And so, that shift in focus for deliver of care is very critical. Care coordination, just by virtue of the term, almost didn’t exist in the fee-for-service world. We didn’t have technology. We didn’t have data and analytic. Again, paper charts, telephone calls, that was about it. In this fee-for-value environment, our infrastructure’s set up to give us access to much more data, which we can then use to identify patients to be more proactive.
Finally, just thinking about cost, so I believe that a strict fee-for-service environment really is a bit of a perverse incentive. I mean, you, people say you, whatever you incent is what you will receive, what you will get. And incenting people to do more usually gets you more. And that’s the way the fee-for-service structure was set up. It’s set up to do more. See more. So, the important thing was, you know, who’s on my schedule, do I have enough people to see, am I seeing as many as I possibly can. In a fee-for-value world, the financial construct is more conducive to seeing the right patients, at the right time, and in the right location, and doing the right thing. So, it’s not necessarily doing more. But it again focus on doing the right things for patients. And so those are, there’s certainly more ways, but in my mind, those are some of the big differentiators between how we think in a fee-for-service world versus how we think in a fee-for-value world.