Q&A: Value-Based Payment Models Require New Workforce Approaches

Newer models provide an opportunity to use staffing strategies to fill in care gaps in a way that enhances quality, say leaders with two organizations that are flourishing in the new era.

When making the transition to new care delivery and payment models, healthcare organizations must get comfortable with managing change. Implementation of models such as accountable care organizations (ACOs) requires new skill sets, new roles, and new approaches to working together throughout an organization.

Two organizations that have made notably successful transitions are Advocate Physician Partners (APP), a clinically integrated network that is based outside Chicago and part of Advocate Health Care; and Memorial Hermann ACO, based in Houston and part of Memorial Hermann Health System. Both are among the top-performing ACOs in the Medicare Shared Savings Program.

In this Q&A, Don Calcagno, president of APP, and James McCarthy, MD, executive vice president and chief physician executive with Memorial Hermann Health System, describe workforce strategies that help organizations incorporate the necessary changes and align their resources with new models of care.

What are some key components of a value-based staffing model that may be different from standard payment models?

Don Calcagno: The standard payment model fragments the continuum of care. If you look at it from a workforce or staff perspective, they have a very well-defined beginning and endpoint for their job responsibility. They know where it starts, they know where it stops. In many ways, unfortunately, it’s not a formal job accountability to ensure there is a crisp or clean handoff or transition between their scope of responsibility and somebody else’s.

Value-based care is more about having care that’s provided at the most appropriate site. It’s much more about coordinating across the continuum. It’s also a little squishier between where your job begins and ends.

Staff need to really see their roles as helping patients across the continuum. If it’s an episodic procedure, they need to make sure the coordination is a well-oiled machine so that the patient receives seamless care—which, in our view, results in a lower total cost of care and provides better-quality and safer care. If it’s chronic care or wellness care, how do we make sure the patients aren’t falling through the process cracks?

In the value-based world, it’s more about a tight handoff between the sites of care and between providers. In some cases, you might have to have extra resources to close the gaps.

James McCarthy: An ACO model allows you to be creative in using additional personnel resources that are typically unavailable in a traditional fee-for-service model because there is no mechanism to fund them.

Critically important to the ACO is to first get an integrated network. You’ve got to bring all the physicians together and get them all onboard with what we’re trying to do, with the fact that we’re going to be looking at things a little bit differently.

A second thing was using care managers to help primary care physicians better manage their patients. By that, I simply mean being able to get the information to the physicians to make it easier for them to do the doctoring work and to keep track of people. We developed care managers and fleshed out a certification for a medical home so that we had a primary physician office serving as a medical home for a panel of patients, and then overlaid digital tools on top of their charting system to allow them to keep track of patients in ways that we know or that we believe would help keep them in a lower-cost platform through the ACO—annual screenings, making sure physicals are done, making sure follow-ups are done.

Another critical component of that was making sure there were robust data analytics so that we could have regular meetings with our integrated physicians where they reviewed unblinded data, seeing how they were doing compared with their peers and then being able to share best practices and identify outliers who needed specific, targeted education.

One thing that didn’t necessarily become obvious until you really started digging into it was providing an increased social work presence—both in the doctor’s office but then also in post-acute settings to help identify other barriers to care.

It’s really the supportive network that you can build with care managers, social work, and digital tools. Those are some of the staffing pieces and informatics that you need to be able to lay on top to make these networks successful.

To what degree may additional staff be needed for an ACO or other type of value-based model to succeed?

McCarthy: The utilization of social work and care managers in the outpatient space is really not common once you get outside of an ACO model. We can talk about things that these folks are able to identify that often get missed in a standard model by primary care, or if they’re identified, the primary care physician doesn’t have the tools to help. Things like social determinants of health, food insecurity—asking those questions. Prescription costs, medication costs—figuring those out and helping patients navigate cost solutions for medications. Helping them navigate their living scenario.

If you talk to a physician in a primary care clinic that doesn’t have robust case management or social work support, they may be hesitant to ask about food insecurity because they don’t have a solution for it. Bringing those things to the surface helps you address the constellation of the social determinants of care that don’t come up in a routine healthcare visit. You need to add those people in, and in an ACO model, you can.

The other part is expanding access. We added a nurse treatment line so that patients have more ready access to advice and care navigation, so we can get someone the kind of contact that they need 24/7—especially in this increasingly consumer-driven healthcare market where you have, at least in our neck of the woods, a freestanding emergency department on every corner. By getting the patient on the phone either through a telemedicine program or through a nurse healthline, if we can redirect them into the appropriate level of care for what they need, we can keep the cost down for the overall program while still providing that rapid patient contact and touch that they need to feel secure in their healthcare network.

These models clearly allow the evolution of our healthcare economy and market into what people have been talking about for years. How do we keep people healthy instead of taking care of them when they’re sick? These are the models that provide the resources to be able to do that.

Calcagno: I do think new staff positions are going to be required for ACOs. We’ve started a pilot that we call the Care Transitions Team, or CTT. Its purpose is to call patients who are in our value-based contracts or who we see as high-risk or rising-risk.

In that model, a nurse calls a patient after they’ve been discharged from the hospital and follows up on key transition areas. It could be medication reconciliation, or did they get their follow-up appointment, did they understand their discharge instructions—things like that. That’s a whole new role that we never had before.

We’ve seen significant reductions in readmissions and in safety-related issues. Like somebody got discharged on two blood pressure meds because of confusion with the medication order changes. Or somebody didn’t get their oxygen delivered. The CTTs have really tightened up the meds reconciliation. That, we believe, has been a key driver of better care for the patient and lower unnecessary utilization.

What roles take on increased importance in newer models?

Calcagno: The most significant roles are going to be those that are really about that comprehensive transition across the continuum. Navigators are great examples. How do you make sure that the patient gets the high-quality, safe care they need, which we firmly believe will be lower-cost? Who’s helping to make sure that they’re not falling through the cracks? The healthcare system is way too complicated as it is, and when patients are most vulnerable is not a good time for them to try and understand how to navigate the system. It’s our job to try to simplify a complex system.

In addition, I think we need better data and analytics tools because we have to more systemically understand where the opportunities are so that we can really get after improving care. When you read about social determinants of health, you realize the cost of health care is really only 10 percent driven by care costs. There’s the famous quote that ZIP codes are more important than genetic codes when it comes to the quality and cost of health care. So how do we begin to understand that? And who is responsible for closing social-determinant-driven gaps?

McCarthy: Care managers are the ones who really help the physicians oversee their whole panel. Having someone with some high-level oversight of what your practice is doing and being able to share the data with you is helpful. You need some coordinators at a higher level who are looking at a whole field so that individual practices don’t just get lost. They need to be out and be deployed to the offices, so it’s not just someone sitting and looking at data in their office, but you have resources to go out and integrate with all those physician practices to help them with their patient panels.

What additional training may be needed for clinical, administrative, and support staff in preparation for a value-based model?

McCarthy: The fact of the matter is that these doctor’s offices were not seeing only ACO patients. The ACO, for some of them, may have been a relatively small part of their practice.

At least until we flip everybody into models like this—if we ever do—the regular business of running the clinic had to operate the same. We couldn’t disrupt these physicians’ practices by reeducating everybody. We needed the office to basically work the same. We just layered support tools on top to help them manage this special population.

Calcagno: I think there needs to be training for additional capabilities built around data. We have a dedicated team that focuses on analyzing data and outcomes. They do design testing and scale innovative projects. When we think about IT systems, data science, and all that knowledge around the value chain and medical benefits—people need to understand analytics and draw conclusions that will drive actions, but then somebody needs to digest that information and provide very crisp, clear information to the clinician, to the bedside person, to the navigator on the phone.

I don’t need the people who are seeing the patients to know how to do a multifactorial regression. I need them to understand that in analyzing the data, we know A = B = C. We need people who are really good at doing the hardcore, analytic work to move from data to conclusions, and we need people who understand how to translate and communicate that to somebody who can do something with it.

How can staff prepare to engage in the level of coordination that is needed to ensure the success of an ACO or other type of value-based model?

Calcagno: It’s imperative that as healthcare leaders we work with our frontline staff and patients to understand the best organizational structure and the accountabilities to improve the coordination of care across the continuum.

We also need to create a high-reliability organization—which Advocate has been focused on for many years with great success in reducing safety events—where a frontline worker feels empowered to do the right thing, to escalate through a chain of command if something is putting a patient at risk and to report any near misses or serious events that will stimulate a corrective action to improve the process.

McCarthy: Anytime you’re overlaying new people who are going to swoop into an office and start looking over people’s shoulders about stuff, you’ve got to prepare the group that this is not someone who’s going to be a big brother; they’re an added resource to help take care of these patients. You’ve got to have a dialogue with the staff about that.

It’s all about doing this with grace. But most of the time, if you build it up and you say these people are here to help and here’s how they’re going to help, and they actually do help, there’s very little resistance to bringing that in.

It was important to make sure these folks were viewed as a new resource—to add positions, add the social workers, add the care managers. These people were really looked at as people who were helping you do your job, not telling you that you had more work to do.

If you try to do this without resourcing the positions that make it possible to achieve the savings, you’re not likely to be successful. There’s absolutely an investment in human capital, in education, to get people in position to do the things that we know we can do to save money. You can’t just lay this on top of a busy practice that’s trying to get everything done and expect that you’re going to be as successful.

How can cooperation between providers and payers help ensure the success of value-based models?

McCarthy: One thing that is very important is to make sure that we have access to high-quality data very quickly. An example is some of the biologics, some of our newer medications that are extremely expensive—having real-time access to the data about where they were being prescribed so that we could understand if they were being used in a medically appropriate manner. Having that data up front is very, very important.

Also having routine meetings and phone calls not just on pharmacy costs but on other practice-visitation matters. For example, in an ACO model, depending on whether a patient is one of our covered lives and goes into the emergency department, that information may not come back to us quickly. It’s very possible the primary care physician never gets a phone call, especially if it’s a competitor network. We need real data about which patients are utilizing the system in a way we may not have optics on because they’re not touching our primary care lives or they’re not touching our hospitals.

Having that data is very important so we can get our hands around patients who are falling through the cracks. That only happens with frequent dialogue and interaction with the payers because they’re, of course, seeing the claims come across in real time.

Calcagno: What’s interesting to me is that positions like these that we’re talking about, they require funding because in a fee-for-service model, nobody’s paying for these resources. If there’s not a global cap or some type of shared savings or care coordination fee that’s somehow paying for me to have a very skilled person on the phone, that’s not insignificant as an expense.

One of the things you’ll hear us talk about at Advocate is that we firmly believe we have to all move into global capitation because then we can fund these things that we know add value, such as a care transitions team. Otherwise, who’s going to pay for it? That service doesn’t happen if there’s no funding for the resource.

Historically, in my mind, this is where it falls through the cracks. The payers like to think they’re doing it, we like to think we’re doing it, but in the end, we need to coordinate and work together. Otherwise we cause confusion for our patients and members. 

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Nick Hut is managing editor of Leadership.

Interviewed for this article: Don Calcagno, president, Advocate Physician Partners, Rolling Meadows, Ill.; James McCarthy, MD, executive vice president and chief physician executive, Memorial Hermann Health System, Houston.