Phase II: A Value-Based Collaborative Care Model by Payers, Providers, and Pharma

J Clin Pathways. 2022;8(6). doi:10.25270/jcp.2022.09.1

The year 2021 marked the second year that a group consisting of a payer, several specialty providers, a pharmaceutical manufacturer, an analytics organization, and a team of value-based care architects worked together to develop a Specialty Care Medical Home model for managing the care of individuals with psoriatic arthritis (PsA).¹ The goal was to leverage the expertise of multiple stakeholders and build a whole-person, team-based, collaborative care model that would address the full spectrum of care required to get to consistently optimal outcomes and reduce downstream adverse events and associated costs. The charge for 2021 was to develop a collaborative care model that could be implemented as a pilot in-market, which could be used as a template for building similar models to address other chronic conditions.

The goal of any value-based care model is to optimize quality and cost of care while enhancing patient experience and outcomes. To effectively do that in the chronic care space requires that the model support patients’ ability to follow their prescribed protocols on an ongoing basis. This means the Group needs to understand what it is, exactly, that might limit patients from doing so in the first place. It is critical to consider that part of patients’ inability to adhere to their treatment plan may include providers unwittingly prescribing or directing care in a way that isn’t feasible because of a patient’s unique cultural, financial, psychosocial, theological, environmental, or other social constructs.  And because health care providers typically only see data related to care they delivered (ie, clinical data they collect and claims data shared by payers), providers often do not even have a complete medical picture of their patients and the full spectrum of care those patients are receiving to be able to properly assess and optimize prescriptive care to achieve the best possible outcomes.

Beginning in 2021, the Group reduced its clinical leadership team to the in-market team consisting of two rheumatologists, a dermatologist, and a cardiologist who are anticipated to launch the initial pilot (the Group had begun the exploratory work with some additional physicians from other parts of the country for a more diverse perspective). The 2021 charge for the physicians was to study the data—both clinical and cost—and determine the clinical pathways, based on evidence-based guidelines, that would close the care coordination gaps and consistently provide optimal care to patients with PsA without the overuse of resources.

A clinical sub-committee was established early in the year and had a regular cadence of meetings during which the framework for the model was more clearly defined (Figure 1). The sub-committee was comprised of two rheumatologists, a dermatologist, and a cardiologist working with one of BCollaborative’s clinical advisors (registered nurse and certified case manager, with experience in building value-based care models). The framework included agreement on care guidelines, care coordination, co-specialist coordination (ie, referral processes, in-person vs virtual, etc.), and a recommendation to the larger group about quality metrics.

The physicians engaged to determine the appropriate clinical pathways to utilize as the framework. Clinical data was reviewed, as well as claims data, to understand where the greatest variations in care and cost of care are for individuals with PsA. Discussion included guidelines from the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA), the European League Against Rheumatism (EULAR), and the American College of Rheumatology/National Psoriasis Foundation (ACR/NPF).

Reference was made to literature, which was inclusive of the following²:

Overall, the sentiments of these principles were very similar across the three sets of recommendations: (i) the goals of therapy are to improve quality of life and function and prevent structural damage and complications; (ii) this is a disease that requires multidisciplinary care so engage other practitioners as needed (dermatologists, gastroenterologists, etc.); (iii) shared decision making is an important principle of optimizing treatment decisions; (iv) identify and consider comorbidities as they impact treatment selection.

After much thoughtful discussion, the clinical sub-committee ultimately decided on the ACR/NPF pathways as the foundation (Figure 2). The key reason for using the ACR/NPF guidelines was the nuanced approach and specialty practice acceptance.

Quality Metrics and Outcomes

The clinical sub-committee made the following recommendations to the team regarding quality metrics to determine success:

• In-patient hospitalization rate
• ER visit rate
• RAPID3 PRO (Year 1 measure. Years 2 and beyond will include disease progression as the outcomes metric, replacing the screening tool process metric.)

Each metric will have a threshold of performance that will be measured. It is important to point out that value-based models are reviewed based on outcomes metrics and not the typical process measures that health plans have historically required (ie, health plans often reward physicians for following certain guidelines, practicing medicine as the plan has directed).

There are challenges in measuring a comprehensive set of outcomes that come from a variety of disconnected sources. That said, the clinical sub-committee wanted to use disease progression as its outcome metric. However, as there is no baseline yet for this information since rheumatologists do not measure consistently to data that is not captured on a claim, the team needed to develop a way of achieving the outcome metric point.

The sub-committee decided to use the RAPID3 as a patient reported outcome (PRO) measure of disease activity, physical function, and life impact (Figure 3) for the first year of implementation. While the tool itself is a process measure, its use will deliver the information over time that will show the progression of disease which can be measured against established benchmarks. After this first year, the team will review the data against the benchmarks (which are still to be set) and will use the RAPID3 PRO as a tool to understand disease progression, which is one of the key clinical outcomes metrics the clinical sub-committee has recommended to the large team.

CrossBridge, the Group’s analytics partner, built the clinical algorithms using ACR guidelines as defined by the Group. The algorithms included claims and clinical data integration and is expected to include social determinants of health (SDOH) information and show variations in care and cost of care. The algorithms ingest the PROs from the RAPID3 to show those outcomes in relationship to changes in clinical care in a longitudinal view. The CrossBridge model allows for tracking patient cohorts along the pathways and illuminating key differences, including comorbidities, age, gender, concomitant therapies, and total cost of care (Figure 4).

Understanding The Social Drivers Affecting Health Outcomes

The team aims to build a foundation within this PsA specialty care medical home (SCMH) that will support physicians and other care providers in their ability to provide comprehensive, coordinated care to their patients, and support patients in their ability to follow the treatment plans prescribed. There is a need to develop care plans that fit the unique needs of each patient, essentially being a customized approach for each individual patient, based on the collective and aggregate tools and data shared by all partners.

The team met with several vendors of social determinants of health-specific data, all with unique insights and capabilities, the best of whom can combine their patient-level data with clinical data to better inform care management and clinical outcomes.

It is becoming more and more widely understood and accepted that a patient’s SDOH has a significant impact on their ability to follow prescribed protocols and achieve optimal outcomes.³ In addition to clinical insights, it is critical for care providers to understand individuals’ support systems, home environments, transportation, proximity to pharmacies and other health care providers, health literacy, and more in order to help patients achieve optimal outcomes.

Care Coordination Teams

CareFirst, the payer partner of the group, brought its health economics team—experts in community health and social impact dedicated to improved access and affordability—to several conversations to understand what may already exist within the CareFirst enterprise and what is planned in the coming years.

CareFirst also brought its behavioral health lead to the table this year, as the Group understands the strong interconnection between the physical manifestation of disease and behavioral health. Specifically, the Group wanted to ensure that patients have access to behavioral health resources and providers and that both are incorporated into care coordination. With an evolving health care landscape and many elements of care now delivered virtually, this has never been more urgent.

Many behavioral health practices have adapted by utilizing virtual platforms to deliver care. The Group discussed using a virtual platform and tools to ensure that physicians and patients have awareness and access to behavioral health specialists within the community, especially in under-served areas, and to broaden and strengthen the social support fabric of the SCMH.

As of January 2022, the specifics of the claims data and what can be shared has yet to be confirmed. There is ongoing discussion around the level of granularity that is required to support the patient across the health care spectrum, as well as what the payer can comfortably and legally share.

The Group is working to identify the level and format of data that will provide sufficient insights to guide clinical decisions and support patients across the health care spectrum.

Model Design

The Group contemplated what the underlying payment model that supports the collaborative care model should look like. They studied and weighed the options of a no-risk model (ie, none of the financial risk is shifted from the payer in the first year) or a model in which the care provider team would accept some risk (ie, if performance failed to meet quality and financial targets, it could owe money back to the payer).

Interestingly, one of the physicians felt that it was important to take some risk to get real engagement.  The Group, however, ultimately decided that it wanted a model that supports the partners as they learn how to work within this new construct, rather than one that might only increase the mistrust and fear that already exists.

There are existing regulatory barriers that complicate a true “down-side” model. With that backdrop and an interest in easing the transition from fee-for-service to value-based care, there was consensus that a shared savings approach without the immediate shifting of risk to the clinicians may be most appropriate, evolving as the specialty care model is fully realized. This model will allow the providers to continue to be paid at contracted fee-for-service rates, while getting a first-time view into the additional care that patients are receiving.

The no-risk model will give the partners the opportunity to put the new pathways and workflows in place, assess best potential partners, ensure they have the required data, and understand how to successfully work within this new framework. The care providers will continue to be paid by fee-for-service, but at the end of each measurement period (ie, generally 12 months), the year’s care and costs will be assessed to determine if quality measures were met and savings achieved, leading to additional payment to the providers.

There was acceptance among the group that it was important to invest the time to study the data and understand where the opportunities are to improve care and reduce overall costs before engaging in a risk-based model. The Group agreed that adding a risk component in future years made sense.

One of the many benefits of working with engaged provider groups is a willingness to speak candidly on a range of topics, including the anxiety of embarking on something new and not knowing what exactly the outcome might look like. In a fee-for-service model, the drawbacks and benefits are well understood. Engaging in value-based care models is new for most specialists, and there is significant fear around losing the ability to make clinical decisions, experiencing a loss of income, and having less control over their patients’ care.

Establishing a culture that respects the expertise of all stakeholders has been critical to ensuring clinicians remain in charge of the clinical care, while also ensuring that clinicians do not get punished for overuse of services while they learn.

Acknowledging full insight to the variations in care and costs of care that impact outcomes is dependent on a comprehensive data analysis, there was agreement that the team could still move forward on refining clinical and referral workflows and a general framework of care before it had a complete and up-to-date set of claims data. While not ideal, the Group respects that the payer partner must assess what and how it can best share the longitudinal data that is required

A no-risk model is a thoughtful and important step. It allows providers to participate and study the claims and data and identify the most effective and thoughtful use of resources, as well as identify appropriate prospective partners. A no-risk model provides an opportunity for the payer, provider, and stakeholders to learn how to create successful partnership without the providers fearing the loss of their ability to make decisions and render care as they see fit.

The willingness of parties who may have never contemplated partnering with in the past to come together, and listen and respect the expertise of each other, has been extraordinary and of paramount importance in the development of this complex model, and will be the keys to building models of care delivery and payment that will address the needs of those living with chronic conditions most effectively.

Authors: Lili Brillstein, MPH¹; Mary Aikins, RN, CCM²; Michael Udwin, MD, FACOG³; Eric McCulley, RN⁴

Affiliations:¹CEO, BCollaborative 
²Value-based Care Consultant
³Medical Director, CareFirst BlueCross Blue Shield
⁴Head of Portfolio Innovation, US, UCB

Address Correspondence to:Lili Brillstein, MPH
Phone: + 1 (917) 733-5864
Email: lbrillstein@bcollaborative.com

Acknowledgements: The authors would like to thank Drs. Herb Baraf, Evan Siegel, Sara Collins, and Benjamin Lockshin for contributing their expertise to this project.

Disclosures: Lili Brillstein served as a paid consultant to UCB for this project. The collaborative project detailed in this article was funded by UCB.