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How Delivery System Leaders Are Linking Prevention, Reimbursement, and Value-Based Care

Analysis  |  By Laura Beerman  
   August 23, 2023

Execs from diverse organizations share their strategies.

"We have providers all the time saying, 'I want a value-based contract.' But when you ask them why, they have no idea." — Chasity Howell, Vice President of Provider Relations for Indiana Medicaid MCO MDWise

"Value-based care really is a shift in the paradigm. Providers deliver care on an individual patient level. Now, we're asking them to deliver care at a population health level. This is where practices need to change how they operate." — Dr. Nancy Klotz, Chief Medical Officer of third-party administrator Brighton Health Plan Solutions.

These quotes from the HealthLeaders Payer NOW Summit capture the abiding challenge of value-based care: what it actually means, how to deliver it, and how providers can embed preventive care in VBC models. Read on for more highlights from the panel: Preventive Health: Coverage and Reimbursement on the Chopping Block?

HealthLeaders: Preventive care is defined differently across organizations. How does your organization define it, and what flexibility do you have in implementing preventive care protocols and reimbursement?

Chasity Howell, MDWise: As a Medicaid managed care plan, we define preventive care as whole person health. We follow Indiana state guidelines, but we try to think kind of outside the box including how we can impact members with social determinants of health. When thinking about preventive care, we also engage our care managers on issues that interfere with a member having a healthy day-to-day life — things like diabetes and other chronic conditions.

Dr. Nancy Klotz, Brighton:* Preventive care really is a more encompassing type of care that addresses what patients or the population need. Some folks are ill, some folks are healthy.

First, we borrow from the experts in the community: NCQA HEDIS and their guidelines to define what we deliver as far as preventive care. That's divided into preventing disease [e.g., via screenings] and then managing those who have disease and making sure it hasn't progressed. Those are the two main categories. Then there's the category where we don't know we don't know what we don't know. Here, there are things that can help like the Medicare annual wellness exam, functional assessments of the activities of daily living assessments, and pain management assessments.

HL: If this year's federal court decision blocking select no-cost preventive services is upheld, what kinds of coverage decisions will you face and what advice are you providing in light of this uncertainty?

Howell: If for some reason the state of Indiana decided that preventive care was no longer going to be covered at the same level, it would definitely have an impact on us. At MDWise, preventive care is something we've implemented into our mission and our vision of being a health outcomes leader in the state we live in. It really comes down to doing what's best to keep members healthy, understanding their benefits, and educating providers on how best to be reimbursed for those types of services.

Dr. Klotz: There is a lot of concern. There are more than 60 physician-led organizations that are opposed to what's happening right now in the preventive care scenario . . . But even if the Affordable Care Act went away, there are 15 states that have broad ACA-style laws that require individual market insurance to cover prevention without cost sharing . . . At Brighton, we are going to continue to offer these preventive service guidelines and per our client's wishes, but we will strongly urge them to continue with them regardless because make good sense — from a medical perspective, a health perspective, and a financial perspective.

HL: Share a specific, unique solution that your organization has encountered related to preventive services reimbursement that others can learn from?

Howell: The solution that we have tried to shift toward is the value-based care model, reimbursing providers for quality of care and patient outcomes. That really encourages a focus on prevention against costly care on the back end. We also recognize the impact of social determinants of health, and we're trying to find a unique way to reimburse providers for things like housing instability, food insecurity, transportation issues. There's also collecting and analyzing the data so we can work together as provider and health plan, target at-risk populations, and identify interventions that address those specific needs.

Dr. Klotz: With regards to reimbursement, it all depends on the clients that we contract with. That being said, we conduct our financial analysis and find the highest-cost items, including those that might have been avoided if there had been preventive services in advance.

As an example, I spoke with a fund administrator and noticed that cardiology, kidney failure due to diabetes, and dialysis were high-cost items. We designed a program to ensure patients see their nephrologist as part of their dialysis and promote the use of statins. We promote mail-order pharmacy, where there's less of an opportunity for missed dosages. We also have a behavioral health case management team and are contracted at preferential rates with certain organizations to help expedite member appointments and even reserve appointment slots to ensure access to care.

HL: Preventive services should be the secret sauce of value-based care. Why aren't they, what role does reimbursement play, and what do we do about it?

Howell: Moving to value-based care for providers is super important because it stresses preventive care services, the impact on the total outcome for the patient, and the role of the overall care that they provide every day. So, while little Johnny is coming in for his ear infection, does he need a well visit? If he's scheduled for one, will he be able to get back for it. And while he's here, is there anything else we can do to make the most of that visit . . . There are a lot of providers who are shocked when they see their missed opportunities.

Dr. Klotz: Most providers are a little hesitant to take on risk and have skin in the game. If their outcomes are bad, it may be due to their lack of attention to preventive guidelines, but it's also multifactorial because now providers are taking on the burden of addressing social determinants of health.

Another barrier that needs to be addressed is that the definition of value-based care is still a bit vague.

And lastly regarding incentives, they don't always work. I think they work when there is a significant portion of providers practicing and, let's say, 10% of their income is based on incentives.

*Brighton Health Plan Solutions Disclaimer: Contents are for informational purposes and do not constitute legal or medical advice.

Laura Beerman is a contributing writer for HealthLeaders.


Prevention should be the secret sauce of value-based care. Why isn't it and how can the industry change that?

Executives from Indiana Medicaid MCO MDWise and Brighton Health Plan Solutions have answers.

They include how we define, reimburse and support provider-driven preventive care.

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