4 unique perspectives on value-based reimbursement: Hurdles, fears and ideas for collaboration

As healthcare organizations begin to shift to value-based care, it becomes evident physicians, hospitals, payers and pharmacies will need to work together in ways they never have before.

"Clearly [the shifting healthcare environment] will result in fundamental changes in how healthcare is reimbursed, how healthcare is delivered and how patients interact with healthcare systems, all of which has tremendous potential implications for us, regardless of where we sit," said Jonathan Niloff, MD, vice president and CMO of McKesson Connected Care & Analytics. "We are all, in one way or another, constituents of the healthcare system."

Dr. Niloff moderated a panel of thought leaders from each sector — hospitals, payers, pharmacies and physicians — at a McKesson-sponsored event Tuesday, part of the 2015 Annual HIMSS Conference in Chicago.

The following thought leaders shared what value-based care means to them, the challenges they face, their fears and best practices to survive the transition.

1. Steve Stanic, vice president and CIO of Mississippi Baptist Health System in Jackson. For Mr. Stanic, who is responsible for information technology, telecommunications and organization performance improvement at the Mississippi Baptist Health System, access to quality data and technology are the keys to achieving success with value-based reimbursement. He named the lack of interoperability and data transparency as top roadblocks to value-based care, citing specifically the need for a national patient identifier.

"If we had a way of identifying patients it would make it much more seamless from payer to provider," Mr. Stanic said. "I look at it as the Holy Grail."

After interoperability and data transparency are achieved, Mr. Stanic believes the next priority will be helping physicians, particularly primary care providers, process the tsunami of information they will be receiving.

2. Derek Weiss, RN, vice president of provider service and experience at Bloomfield, Conn.-based Cigna. Mr. Weiss is responsible for end-to-end engagement and service experience at Cigna He also ensures Cigna's clinical and delivery goals are aligned. One of the biggest challenges Mr. Weiss sees in transitioning from fee-for-service to value-based care is finding ways to create quality outcomes and incentivizing those outcomes in ways that fit with diverse markets and payment systems across the country.

While both payers and physicians work in both the fee-for-service and value-based worlds, Mr. Weiss believes it will be a challenge to transition to value-based care without harming the quality of care in the fee-for-service world.

"I think we're all trying to figure out how not to disrupt things as we build a new future," Mr. Weiss said.

In terms of technology, Mr. Weiss believes a focus on analytics — pinpointing patient data in a useful way to manage patient outcomes — will make value-based care successful. To make this process easier from a payer perspective, connectivity, data storage and the transmission of information to the physician need to be streamlined, he says. Challenges are inherent in this transition, according to Mr. Weiss. Understanding the technology and being able to deal with excess data will be critical to this transition.

3. Tim Wright, PharmD, BCACP, partner at Clinton, Iowa-based Wagner Pharmacy Company. Dr. Wright leads the fiscal and business strategy at Wagner Pharmacy and serves as a retail and long-term care pharmacist. From his vantage point, the challenge of value-based reimbursement is providing meaningful feedback to physicians and hospitalists so they can engage patients. Because pharmacists cannot operate on a purely value-based system due to the commoditized nature of their products, Dr. Wright stressed it will be key to make pharmacies relevant in a value-based world. While the role of the pharmacist in this world remains to be seen, Dr. Wright believes "The devil is in the data." Pharmacists will be able to provide physicians with important patient information.

This role, as it remains undefined, is one of Dr. Wright's biggest worries about the transition. "In our position, physicians and heath systems are ultimately going to think they can manage pharmacy themselves," he said. "We could lose this opportunity unless we're telling our story."

The biggest roadblocks he mentioned included helping healthcare workers transition and giving them the practical ability to manage the tools at their disposal. "Most healthcare workers are IT ignorant and most IT workers are healthcare ignorant," he said. "They don't think on the same plane."

4. James Whitfill, MD, CMO of Phoenix-based Scottsdale Health Partners.
Dr. Whitfill has a background in radiology and medical informatics. From his perspective, some of the top issues challenging value-based care are cultural and relationship-based.

"I know this is shocking, but many physicians are skeptical of change. I know you think of us as a very progressive group of people," he laughed. "For those of us who are old enough say, 'I've seen this before in the 1990s,' — and I think things are different this time — but a lot of us who were around for the last round of healthcare reform have been jaded by that."

In some larger organizations, he said, there are leaders literally working at odds with other components of the organization: When one vice president may be trying to keep people out of the ED, another vice president may be driving patients there.

Some of this can be improved through better coordination and tools for physicians.

"Physicians can't do this alone. With all the information coming forward to us we have to be able to do a better job of coordinating with our colleagues — between specialists and primary care physicians — and the reality is the physician can't be the lone quarterback doing all this. We have to be part of a team with care coordinators and pharmacists, and you need software to do this."

However, part of coordination is alignment, and to be aligned healthcare professionals must operate on trust, Dr. Whitfill said. He named a series of relationships: payers and healthcare providers, physicians and hospitals, employers and payers, employers and employees, and patients and physicians.

"I don't know about you, but some of those relationships could use a group hug," he said. "I think trust is a big issue, and if we're going to solve this we need to have trust between those partners. I think alignment of incentives helps build that trust."


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