How value-based care can save your practice

Primary Care is in the midst of a crisis. Many practices face a threat of closure as they deal with the fallout from the COVID-19 pandemic. So what can physicians do to save their practices and treat their patients effectively?

Farzad Mostashari, M.D., says physicians should embrace risk.

And by that he means value-based care. Mostashari contends that the fee for service system has exacerbated these financial struggles, and that the way forward is to accelerate the evolution of how physicians are paid for providing care. In a wide-ranging conversation, we discuss value-based care, telehealth, and what the ideal primary care practice of the future should look like.

Mostashari is the former director of the Office of the National Coordinator for Health IT and currently CEO of Aledade, a company that assists small practices with transitioning to value-based care models.

This interview transcript has been edited for length and clarity.

Medical Economics: What is the state of primary care right now? What are they going through and how do we get how do we fix primary care so that they can succeed in the future given the challenges?

Mostashari: Primary care has never been more needed. We have obviously a lot of need for primary care on the front lines of COVID-19. We all hear about hospital workers who are at risk of COVID-19, but those patients who end up in the hospital first went to their primary care practices. And those primary care doctors aren’t like you and me, who get to stay home and socially distance ourselves. Those primary care practices are exposed to every patient who walks in the door, and they care for them. They close the door, in a room with them and often with inadequate personal protective equipment, because the supply chain for those small practices is broken, they could not order masks.

These primary care heroes have been caring for patients and also helping patients stay home and healthy and giving them the message of: ‘Don't come in if you don't need to.’

But that means under their current business model of primary care, it means they go broke, because the only way they have been getting paid is by doing visits — not by answering phone calls or reaching out to patients. And so at the very time that we need primary care the most, we see more and more practices who were in fee for service threatened with going out of business.

So it's not a good time for primary care. They're worried about themselves. They're worried about their family members. They're worried about their staff, and they're worried about how to make payroll.

Medical Economics: I'm wondering what you think needs to happen to save these practices from financial ruin?

Mostashari: This is quite topical. [Recently] Blue Cross and Blue Shield of North Carolina announced a program that we've been working with them on for some time now, where they are leading the way on this issue from any health plans, in terms of thinking of what should be done to save these independent primary care practices. Quite simply, what they're saying is, we will give you a lump sum payment to make up the loss of revenue that you had this year. There's no claw back, if they miss calculated, there's no additional reporting requirements.

The one requirement is that you enter into a total cost of care accountability contract. Aledade is honored to be the partner and helping support those practices and succeeding in these value-based contracts.

And guess what? If you're in one of those value-based contracts now you're less dependent on fee for service. Our North Carolina practices, like those in other parts of the country, are getting hundreds of thousands of dollars in payments — not for patients walking in the door, but for patients being healthy and at home and not having to go to the hospital. That is what we should be doing. We should be keeping primary independent primary care practices whole and using this as an opportunity to move towards value-based care.

Medical Economics: How do you see value-based care approaches evolving given this cataclysmic event that has occurred?

Mostashari: It's a cataclysmic event as far as fee for service goes, with hundreds of billions of dollars of bailouts required to compensate hospitals and others for lost revenue from people not walking in the door for fee for service. Value based care is fine. It hasn't needed a bailout. The ACO models are pretty robust. You have to say, ‘Can we be better than if we weren't in an ACO? Can we respond faster to the needs of the patients? Can we educate the patients? Can we take care of their preventive care? Can we deal with care transitions? Can we deal with our medication issues?’ All of the things that we're working on with our practices to do a good job on the value-based contract is exactly what you would want to do for your mom at the time of COVID-19. Right? You would want her primary care practice to reach out to her and let her know like you can call us, you can call us first, we'll see you on video, we'll talk to you on the phone. If you have any problems, we'll send you a 90-day prescription, so you don't have to go to the pharmacy in person. It's all the things that you would want done and if you do end up in the emergency department, we'll call you and see how you're doing and follow up with you. That's what that's what we should be doing anyway. It's just that the current payment system didn't support it.

Medical Economics: Telehealth utilization has skyrocketed. What is the link between telehealth and value-based care and how can we strengthen that link?

Mostashari: So telehealth has a long history of problems with getting paid for it, because the concern on the part of the health plans and Medicare and others is it's not going to substitute for face-to-face visits, that it's just going to be additive, and it's going to increase costs, and it’s going be harder to trace for fraud and abuse purposes. All of those issues are suspended now, because we can't get any face-to-face visits, and this is a substitution for the loss of care. But when things go back to normal — and things will go back to normal — the question is whether this [telehealth surge] is just a blip or whether this is going to be the new way of delivering care. And I think people are being too optimistic to assume that all the flexibilities and the parity that has come with telehealth during this period is going to continue.

I think the solution to that is taking risks. The solution to that is saying to the health plan, ‘Hey, we're not going to run up the bill on telehealth because we have an incentive to care about the total cost of care. More risk is more freedom, in that sense, because if you're on the same side with the payer, then they'll say, ‘You’ll deliver the care however you want to deliver it, I don’t care, because you have the same incentives to keep the person healthy and out of the hospital, as opposed to running up the bill.’

Medical Economics: Right now things are opening up in much of the country while there is also a surge in cases in many places. So you have to kind of navigate this fine line of doing what's right in terms of not seeing patients in person with keeping your business afloat. What are some ways to navigate these challenges?

Mostashari: The good thing about working with independent practices is that the North Star is what's best for the patient, sometimes to the detriment of their business, right? Whereas, if you work for an organization that's got a big finance department, then the finance people can tell you how you should practice medicine. That's not the case with these independent practices — they do what's right for the patient.

What's right for the patient in this case is: If we can deliver care to you remotely, we should do it that way. And if you have potential COVID-19, then we need to keep you and other people safe. So a lot of it has work done now in terms of creating new workflows and protocols for how to do testing in the parking lot, how to keep separate entrances, how to put people behind Plexiglas, how to keep the waiting room empty. So we do have to re-open the practices so that we can get primary care in person to the people who need in-person care, but we got to do it in a way that's safe for the practice staff and safe for other patients.

Medical Economics: Let’s talk about the strain and mental toll this is taking on physicians. What do we need to do to take care of them?

Mostashari: I'm very worried about burnout. I'm very worried about the pressures that are on our frontline primary care doctors and their staff. The worry that that we all feel, and the uncertainty is just compounded when you're a small business owner. You're worrying about your finances, you're worrying about your employees, you have employees that you're accountable to, you may have to do layoffs, you may worry about their safety, and you're worried about bringing COVID-19 home to your family. I don't think it's appreciated enough the daily toll it takes to go in, expose yourself and then come home. I talked to one primary care provider who told me, ‘I come home and just like scrub myself raw.’ Living with that is taking a toll.

Caring for those who care for us, right now we need to do that. And we need to go beyond bumper stickers or signs that say thank you for the essential workers. We actually need to, as a country, follow through on providing them with the support that they need.

Medical Economics: Let's get more optimistic. What does the ideal primary care system and practice of the future look like? Where should we want to go?

Mostashari: Yeah, I'm a cynical optimist. I'm the most optimistic cynic you'll ever meet. Because I'm clear-eyed about what all the challenges are, but I really do think the future can be better.

I think the key is for us to really break the fallacy that fee for service is a good way to pay for primary care, and we've kind of limped along and we kind of made it work based on compassion and professional ethos. And now I think we're seeing this is just no way to run the zoo. We shouldn't be basing primary care payments on that — it should be on the value created and we need to move towards more person-based rather than transactional. Primary care is very much a person based, longitudinal relationship-based kind of work, and we should be paying for it based on person-based longitudinal care, and holding people accountable for total cost, total quality, total experience of care.

And I think that's the optimistic view, is that we will get to the point where we're going to have more freedom for primary care to deliver care the way they see fit.

Medical Economics: What do you think the pandemic has revealed about our healthcare system?

Mostashari: We've talked a lot about the bad part about how broken fee for service is and how we don't have the systems to really support these independent smaller practices. The plus side is you never thought you'd see things move so fast. We saw change within days on policy, regulations, payment models, technology adoption and telehealth. We saw a change in days that you would have thought would take years under the normal course. So that to me is the positive. We have responded. It’s shown that our health care system can still — it's like getting up and sprinting and realizing, ‘Oh, I didn't realize I could still sprint!’ It is a good reminder that we can do it when we need to.

But even as we're in the midst of an emergency, we need to be thinking around the bend. The key is: Solve today's problems but do it in a way that lays the groundwork for the future.

Watch other episodes of Medical Economics Pulse on various topics, including:

• New malpractice risks
• Getting paid for telehealth
• Saving primary care

See all Pulse episodes here.