Tag: provider

Key metrics for value-based care

By Vatica Health | November 18, 2024 | Value-Based Care

Value-based care (VBC) is designed to incentivize providers to improve outcomes in a cost-efficient manner. In other words, payment and quality of care are inextricably linked. Understanding how VBC payments and penalties are calculated can help you better prepare and operationalize your VBC action plan—no matter where you are on the adoption timeline. In this article, we discuss how quality and cost intersect to help providers optimize practice performance in a VBC world.

Key metric 1: Quality

Two of the most critical components of any VBC arrangement are risk adjustment and quality reporting. This is because success in VBC depends on accurately assessing the clinical needs of your population and reporting these needs so that your payments will be sufficient to deliver appropriate care.

The challenge is that risk adjustment and quality reporting are labor-intensive and predicated on a complex set of rules, which frequently become a stumbling block for practices. Because of the complex payment methodology associated with risk adjustment, appropriate coding specificity is needed to accurately report chronic conditions. Without this specificity, plans and PCPs may end up with artificially low patient risk scores, resulting in insufficient funds to deliver adequate levels of care.

Similarly, PCPs must adhere to the reporting standards for quality gap closures. Deviation can result in sub-standard outcomes. For practices that lack specialized coding and quality technology, as well as properly trained staff, keeping up with these activities is a significant challenge.

Other measures relate to preventive health, such as ordering mammograms or colonoscopies. These routine activities are critical metrics for the health plan. Whether they’re process, outcome or preventive health metrics, it’s important that you understand all measures in your VBC programs and how they impact your financial performance.

Whether they’re process, outcome or preventive health metrics, it’s important that you understand all measures in your VBC programs and how they impact your financial performance.

Data for some measures come from standardized patient surveys such as the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) or the Health Outcomes Survey (HOS). Health plans use these surveys to understand how patients feel about access to care, their perception of the quality of care at their physician’s office, and how they feel about their overall health. The questions are not related to the patient’s health insurance benefits; instead, they correspond to the care they receive from their physicians. It’s obvious how physicians influence the responses and why health plans want to partner with physicians to improve scores.

How providers are compensated

Quality of care compensation typically will be paid on a per-patient basis. For example, every time a hemoglobin A1C is ordered or you get a patient’s LDL below 100, the health plan will make a certain payment, usually on a quarterly or monthly basis.

Other VBC models involve a unique set of quality measures. Five or 10 may be needed to achieve a minimum threshold. Or seven out of 10 quality measures are needed to earn a bonus. This is typically the way quality measures are used in a model. A minimum is needed to qualify for a bonus. The bonus dollars associated with achieving a result higher than the minimum can be paid out on a per-patient basis or on the population of patients attributed to a given provider.

Key metric 2: Costs

Costs can be measured in several different ways:

  • Medical loss ratio (MLR)
  • Medical expense ratio (MER)
  • Medical claims ratio (MCR)

All these methods involve taking medical expenses for your patients and dividing them by the premium that they’ve received for that patient. This is the risk-adjusted premium. Another way that it’s measured is by looking at the absolute cost per member—often expressed as per member per month (PMPM). Health plans take the claims expense for attributed patients and divide it by the number of patients you have. This produces a PMPM, regardless of what the measure is.

A common model uses hospital admissions, readmissions and ER visits. Those are big drivers of cost for a health plan. Sometimes, instead of using medical expense ratios or claims PMPM, plans will drive a penalty or bonus program from some of these key utilization metrics. Sometimes, those metrics will be expressed per 1,000 patients so plans can normalize that data. If your practice has 500 patients with a health plan, and there are 10 hospital admissions that month, you might see the metric described as “20 admits per 1,000.” The health plan is creating a standard across all practices so that they can compare results among practices and benchmark how each is doing. Note that some of these programs are purely based on quality, without any cost component.

A study by analysts at Harvard and Humana found Medicare Advantage members treated by doctors in advanced VBC models had 5.6% fewer hospitalizations and 13.4% fewer emergency department visits.

VBC cost vs. quality metrics

It’s important to understand both the quality and cost metrics and any relationship between them. In some cases, PCPs may need to achieve a minimum quality standard before earning any quality or cost bonus. In other cases, there are no minimum thresholds for quality; PCPs are paid as certain benchmarks are met. It matters because more and more of a PCP’s compensation is going to be tied to VBC. CMS expects all Medicare payments to go through value-based models by 2030. Those payments or penalties are calculated by using these metrics. It’s critical to understand what each of the metrics is, how the penalties or bonuses are calculated, and how you are doing today relative to the program’s maximum penalties or bonuses.

Operationalize your VBC plan

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Medical group improves risk accuracy and closes care gaps

By Vatica Health | July 12, 2024 | Provider

Healthcare providers are under greater pressure than ever before and are forced to manage various competing demands for their time and attention. As the transition to value-based care accelerates, so does the need to collaborate with health plans to ensure complete, accurate coding and documentation to inform better risk adjustment and for Primary Care Physicians (PCPs) to actively identify and close care gaps. Patients also want (and deserve) quality healthcare interactions that recognize their unique needs, conditions and circumstances.

Against this backdrop, a lot is riding on the annual patient visit. Amid packed schedules, PCPs need to assess risk, address HEDIS gaps and ensure their patient is properly heard and cared for, with all questions answered and concerns addressed. 

At the same time, PCPs are chronically short on time and resources needed to complete required coding and documentation—often putting in two extra hours a day just to get through EMR backlogs. The continued rollout of CMS-HCC Model V28 will require even greater coding expertise and scrutiny, a troubling proposition for already-strapped providers who are facing burnout at alarming rates. 

Fortunately, by prioritizing and embracing accurate diagnosis coding—and drawing on expert partners like Vatica Health to help upskill PCPs and relieve the admin burden—providers can better identify and manage patient risks, close gaps in care, stay in compliance with evolving guidelines and, ultimately, thrive in a value-based care world. 


Putting PCPs at the center of risk adjustment 

General Physician, PC, one of the largest and most respected medical groups serving Western New York and Northern Pennsylvania, has made it their mission to deliver quality care that’s second to none. Vatica partners with General Physician, PC to overcome the mounting complexity of risk adjustment and lessen the load associated with coding and documentation.

At the 2024 RISE Conference, Richard Charles, MD, Chief Medical Officer and Physician Lead for General Physician, PC, shared his group’s Vatica journey and the role accurate and complete coding and documentation play in helping close care gaps and deliver top-notch care. 

Dr. Charles’ PCPs—like many—needed support on the risk adjustment journey. Dr. Charles and Vatica knew they needed to shift the group’s perceptions that risk adjustment is a benefit only for health insurers and engage the team purposefully in striving for accurate coding and documentation. “There’s been considerable education of our providers around risk assessment,” says Dr. Charles. 

As providers continue to evolve their approaches and protocols in the name of value-based care, continued coaching and education around the upsides of improved risk adjustment—fair and accurate compensation, greater continuity of care, more proactive and higher-quality interactions and more—will separate the leaders from the pack.


“There’s been considerable education of our providers around risk assessment.” 


— Richard Charles, MD, Chief Medical Officer and Physician Lead, General Physician, PC


Empowering teams to deliver quality care

Vatica provides clinical teams plus user-friendly technology at the point of care to enable PCPs at General Physician, PC to capture more accurate and complete diagnostic codes, which helps optimize risk adjustment and leads to accurate CMS reimbursement. A prospective program not only benefits health plans—it helps providers proactively manage care with a comprehensive pre-visit workup of all active and suspect conditions aggregated from various sources. 

Curating only validated conditions and codes prior to the encounter, Vatica empowers PCPs to address HEDIS gaps through necessary interventions, like screenings or medication adherence, and make the most of their time with patients. “That pre-visit summary gets our providers thinking about not just the conditions but what care management is needed,” Dr. Charles explains. “It helps our providers build trust with patients.” 

Vatica also provides group training, one-on-one education and CME courses to help PCPs and their teams understand and overcome the complexities of coding and capitalize on the benefits of better risk adjustment. 


Closing gaps and opening doors

Dr. Charles cites a 10% improvement in risk score accuracy since General Physician, PC partnered with Vatica. He also found specific improvements in hemoglobin A1C levels and blood pressure control, attributed in part to Vatica’s process. “There’s a tremendous improvement in how many HEDIS gaps and how many other care gaps we’ve closed,” he says. 

“There’s a tremendous improvement in how many HEDIS gaps and how many other care gaps we’ve closed.” 

— Richard Charles, MD, Chief Medical Officer and Physician Lead, General Physician, PC


Figure 1: YoY Performance 2021–2023


General Physician, PC has capitalized on improved risk adjustment by using the newly captured revenue to offer additional services. These services give physicians valuable resources to help patients address issues and more time to focus on other clinical tasks and priorities. “We have a large clinical pharmacy program that addresses polypharmacy, high-risk drugs, transition of care, diabetes. We have nutrition, behavioral health, all of which are funded from these dollars,” explains Dr. Charles. “When a patient hears about all the services you have, they become more engaged.”


“We have a large clinical pharmacy program…nutrition, behavioral health, all of which are funded from these dollars.” 

— Dr. Richard Charles, Chief Medical Officer and Physician Lead, General Physician, PC


Better coding in the name of better care

Accurate and complete coding benefits the provider, the practice and the patient. With Vatica as part of its risk adjustment protocol and clinic ecosystem, General Physician, PC has reduced the administrative burden on its team and optimized its diagnosis coding practices. And for Dr. Charles, that goes well beyond time savings or even compliance: “We want to take great care of these conditions, not just document that [patients] have them,” he concludes. 

Maximizing quality of care. Minimizing admin load.

By Vatica Health | July 12, 2024 | Risk Adjustment

Effective risk adjustment drives value-based care performance and promotes fairness and equity in the Medicare Advantage (MA) program by ensuring that payments to health insurance plans and providers reflect the health status and needs of the patients. 

The keyword here is effective. For risk adjustment to deliver on its purpose and its promise, all parties involved—patients, providers and payers—must be coordinated and aligned. The trouble is, legacy programs, such as Health Risk Assessments (HRAs) completed by in-home assessment vendors, remain disconnected from treating providers. While HRAs can be a helpful tool in identifying active conditions, diagnoses captured in HRAs are often not recorded in a subsequent medical visit. Detached programs and practices can undermine the purpose of risk adjustment, increase the risk of non-compliance with evolving regulatory requirements and fail to adequately support and incentivize providers in their transition to value-based care (VBC).

The modern healthcare ecosystem is increasingly complex. Risk adjustment programs that exclude the Primary Care Physician (PCP) are inefficient, create provider-patient friction and amplify risk. Physicians and their teams need a risk adjustment solution that makes coding and documentation easier and leads to high-quality outcomes for their practice and their patients.

Here’s how Vatica Health’s one-of-a-kind risk adjustment and quality of care solution can complement current coding and documentation processes and enhance risk adjustment without overextending staff or sacrificing precious time and resources. 

1. Prioritizes coding accuracy and completeness


Why it matters

Accurate coding is the backbone of effective risk adjustment, ensuring risk scores are calculated correctly and reflect the true health status of enrollees. HRAs, typically performed in-home by vendors on behalf of MA plans, can lead to inflated HCC scores and compromised care.


How Vatica delivers

  • Point-of-care integration: Vatica works at the point of care and proactively surfaces the most appropriate and up-to-date conditions for PCPs to validate. Physicians can focus on their patient interaction, knowing they have a complete and accurate picture of the patient’s conditions.
  • Holistic data collection: Unlike other solutions, Vatica collects and analyzes data from various sources, as well as unstructured data, including consult notes and medical images, offering a more comprehensive picture of a patient’s health. No need for PCPs to connect the dots between various systems and sources.
  • Clinical review: With Vatica, 100% of patient encounters are reviewed by clinicians, such as RNs with advanced coding certifications. This ensures accuracy, completeness and compliance—and offers peace of mind for PCPs.


2. Works with and for providers


Why it matters

Any risk adjustment solution that providers adopt needs to reduce friction, not add to the already taxing administrative load. A flexible and user-friendly solution that meets PCPs where they are ensures effective and robust use, promoting better outcomes for everyone.


How Vatica delivers

  • Provider-centric approach: Comprehensive pre-encounter work performed by Vatica clinicians arms providers with the most clinically relevant information to deliver the highest quality of care during patient visits. Providers remain at the center of care to diagnose, document and follow up.
  • Workflow compatibility: Vatica’s EMR-independent technology works within existing workflows, meeting providers where, how and when they work. 
  • Administrative support: The unique Vatica model includes expert clinician coding support, allowing PCPs more time to deliver high-quality care and assuring that coding and documentation will be accurate, complete and compliant.
  • Payer-agnostic: Vatica is payer-agnostic. Clients include most national health plans and many regional plans. 


3. Supports better outcomes for patients and PCPs


Why it matters

Accurate risk adjustment is a cornerstone of value-based care. Continuing to rely on legacy programs like HRAs and chart reviews that might not reflect the true status of health—and can lead to inflated HCC scores and inaccurate risk-adjusted payments—flies in the face of VBC principles and sets providers back in their journey.


How Vatica delivers

  • Help in identifying care gaps: Vatica flags open HCC coding and care gaps for PCPs to address during encounters. Real-time clinical data assists providers in addressing HEDIS measures during their interaction.
  • Accurate VBC benchmarking: Vatica empowers providers to make the PCP visit the foundation for VBC benchmark accuracy. PCPs can deliver continuous, more effective care and build stronger patient relationships. 
  • Revenue opportunities: Vatica helps PCPs earn additional revenue through reimbursable visits, health plan incentives and enhanced VBC performance.


Better risk adjustment benefits everyone

Vatica Health’s Best in KLAS® risk adjustment solution is designed to help health plans, providers and patients achieve better outcomes, together. By increasing patient engagement and wellness, improving coding accuracy and compliance, and helping identify and close gaps in care, Vatica helps ensure that everyone benefits.

A wave of CMS regulatory changes – a new paradigm for risk adjustment

By Vatica Health | April 10, 2023 | Compliance, Risk Adjustment

By Steve Zuckerman, cofounder and chief strategy officer, Vatica Health

Over the last several months there have been dramatic regulatory changes that will have a significant impact on Medicare Advantage Organizations (MAOs). The Centers for Medicare and Medicaid Services (CMS) made sweeping changes to both the audit process and underlying risk adjustment model, based on concerns with coding of conditions that the government claims are not credible predictors of future expenditures. These changes are against the backdrop of a wave of lawsuits and reports by the Office of Inspector General (OIG), alleging billions in overpayments emanating from legacy risk adjustment models such as chart reviews and home assessments.

Risk adjustment is the foundation of Medicare Advantage (MA). It’s a necessary but complicated process that ensures at-risk entities have sufficient funding to provide the appropriate care and resources to members based on their clinical profiles. As membership in MAOs has steadily increased over the last decade, so have the costs, leading to recent reforms. The first blow occurred on January 30, 2023, when CMS released the final rule on Risk Adjustment Data Validation (RADV Final Rule). This rule authorizes CMS to extrapolate RADV audit findings across a health plan’s entire membership base. The practical effect is that audits will be more frequent, and the new extrapolation methodology will likely result in much more significant fines and penalties (CMS estimates it will collect $4.7 billion more from plans over the next 10 years).  

The government’s next initiative to address coding errors and variations occurred on March 31, 2023, when CMS released the Calendar Year 2024 MA Capitation Rates and Part C and Part D Payment Policies (Final Rate Notice), which shifts diagnosis coding from ICD-9 to ICD-10 and removes over 2,000 codes from the Hierarchical Condition Categories (HCC) model. Despite a massive industry-wide lobbying effort from both payers and providers, the new risk adjustment model was adopted. However, CMS did agree to a phased-in approach over three years which represents a meaningful concession.

Finally, on March 27, 2023, a bipartisan senate bill was introduced by Sens. Bill Cassidy, R-Louisiana, and Jeff Merkley, D-Oregon, entitled the “No Unreasonable Payments, Coding or Diagnoses for the Elderly Act.” This bill seeks to exclude diagnoses from chart reviews and health risk assessments in the calculations of a patient’s risk score. While the bill is in the early stages of consideration, it is consistent with the prevailing perspective and momentum away from legacy models and toward involving treating providers in the risk adjustment process.

The phased-in approach under the Final Rate Notice gives MAOs an important opportunity to review their risk adjustment solutions to make sure they will be effective under the new regulatory landscape. Here are a few practical strategies to consider:

  1. Provider-centricity will be more critical than ever. As we transition to value-based care, it is critical for payers and primary care physicians (PCPs) to work together to improve care, outcomes and costs. Accurate risk adjustment is essential to ensure appropriate care for MA patients, the fastest growing healthcare segment. Therefore, it stands to reason that payers and providers should collaborate on risk adjustment and quality initiatives. Further, given the loss of several valuable HCCs under the Final Rate Notice, it will be more important than ever to ensure the capture and clinical substantiation of all risk adjustable conditions. Legacy models are deficient, work around providers, disrupt continuity of care and don’t accompany patient care plans. A better approach is to empower the PCP with tools and resources to perform HCC coding because the PCP has an existing relationship with the patient, direct knowledge of the patient’s history, and real-time access to the patient’s medical records. Enhanced payer and provider collaboration in this regard can produce better clinical and financial performance.

  2. Reevaluate chart reviews and home assessments. Chart reviews and home assessments that lack connectivity to the PCP and don’t impact care are being targeted by the Department of Justice, CMS and OIG. Both may become obsolete if the “No Upcode Bill” is ultimately passed. Lack of clinical oversight and perverse incentives within these legacy risk adjustment models create an environment ripe for error and malfeasance. Another major concern is that they are not coordinated with treating providers and therefore have minimal impact on improving overall population health and value-based care performance. Consider ways to coordinate your chart review and home assessment programs with in-office solutions to keep PCPs at the center of care.

  3. Focus on accuracy. In light of the RADV Final Rule and the myriad of lawsuits and investigations, at-risk entities should invest in solutions that produce compliant yield. They should focus on improving accuracy and completeness of documentation and coding and include a QI process that reviews both additions and deletions to validate coding prior to submission. The shift to value-based care will put even more pressure on payers and providers to use compliance-centric solutions that are focused on improving the accuracy and completeness of diagnoses codes and documentation.

How Vatica Health can help

Vatica Health is the #1 rated risk adjustment and quality of care solution for health plans and health systems. By pairing expert clinical teams with cutting-edge technology, Vatica increases patient engagement and wellness, improves coding accuracy and completeness, identifies and facilitates the closure of care gaps, and enhances communication and collaboration between providers and health plans. The company’s unique provider-centric solution is used prospectively at the point of care, giving the provider control and ensuring continuity of care. The solution helps providers, health plans and patients achieve better outcomes, together. Vatica Health is trusted by many of the leading health plans and thousands of providers nationwide. For more information, visit vaticahealth.com.

Elevating risk adjustment by activating physician participation

By Vatica Health | March 3, 2023 | Risk Adjustment

As the pandemic subsides, many PCP groups are seeking to restart or ramp up value-based care (VBC) initiatives that took a back seat to battling COVID for the past two years. The economic impact of COVID on PCPs heavily reliant on fee for service and the looming recession will only accelerate the transition to VBC. However, it does come at a time when many providers are short-staffed and feeling overwhelmed.

A recently-released three-year study by JAMA revealed that, between the fall of 2019 and early 2022, the percentage of healthcare workers who perceived emotional exhaustion in their workplace climate increased from 53.3% to 64.9%. The unfortunate reality is that many physicians are struggling with burnout which has been greatly exacerbated by the multi-year COVID crisis. Addressing this challenge requires collaboration and coordination of efforts among payers and providers.

How can care providers and payers work together to activate physician participation in this climate to improve diagnosis coding and documentation, close gaps in care, achieve better clinical and financial performance, and support VBC initiatives? Some answers were offered in a “Bright Spots in Healthcare” podcast.

Moderated by host Eric Glazer, the podcast offered the perspectives of a diverse, blue-ribbon panel of experts:

  • Jeslie Jacob, divisional vice president, provider analytics, reporting and connectivity, Blue Cross and Blue Shield of Illinois
  • Janie Reddy, DNP, FNP-BC, director of family medicine, CommuniCare Health Centers
  • Rebecca Welling, associate vice president, risk adjustment and coding, SelectHealth
  • Lisa Wigfield, RN, BSN, CCM, CRC, CDEO, clinical advisor, risk management, Priority Health
  • Hassan Rifaat, MD, CEO of Vatica Health

Watch the whole podcast to get the full story, but in the meantime, here are some key pieces of advice from the panel:

“The key is to bring the gaps in patient care into the workflow at the point of care.”

Successful VBC is built on data and analytics, but as Jeslie Jacob stressed, gaps in care must be visible at the clinician’s fingertips when interacting with the patient. Jacob emphasized the value of EMR integration and dashboards to ensure that clinicians have ready access to up-to-the-minute insights when they meet with patients.

“Capture as much as you can during the visit.”

Janie Reddy emphasized maximizing the opportunities presented by the office visit. “If a patient comes in for an acute visit – say, for a cough – we treat the cough, but we’re also looking to see if they’ve had their preventive screenings,” she said. “If they’re diabetic, have they had their A1Cs done for the year? We’re looking at the whole picture: all their quality metrics. It’s all embedded in data analytics and presented via dashboards that show us exactly what is outstanding for each patient.”

“It’s got to be documented to capture it.”

Data goes both ways, according to Lisa Wigfield. You’re not just using historical health data to inform the office visit; you’re also generating new, vital data during the visit. For that reason, she cited the importance of documenting everything, thoroughly and accurately. Wigfield mentioned how Priority has enhanced MA benefits and offers a “free to talk” visit that has no copay. The visit provides an opportunity for PCP and patient to talk about health. It’s a good way to address care gaps and discover new issues the PCP may not be aware of.

“Go from a physician-only approach to a team approach.”

Reddy is a firm believer in sharing the VBC workload among physicians and other staff so that the burden doesn’t fall disproportionately on physicians. There are several advantages to this. For one thing, it enables physicians to accomplish more during the time they have with patients. Secondly, it builds a sense of VBC ownership across the entire team. When everyone feels that they are being supported by their colleagues in making VBC work, the effort will be more sustainable. However, keep in mind that a successful team approach requires that each team member has a clear understanding of their role and responsibilities and the practice’s expectations of them.

“Make sure health plan incentive dollars flow down to the practice.”

Incentive dollars aren’t much of an incentive if the people earning them don’t receive them. That’s why Hassan Rifaat, MD, stressed that clinicians should be paid directly for the work they’re doing. He urges practices to “make sure money is flowing down into the practice, from providers to support staff; invest the time to figure out how to do that.” That tangible ROI for the team’s VBC efforts will help ensure their continued commitment. Dr. Rifaat also made a key point about the economics of VBC implementation: “The upfront costs of a VBC program are significant and it can take as long as two years for some of those investments to start generating positive cash flow,” he said. “Once it does, it’s self-funding. But until that happens, some form of subsidy can help providers make the investments needed to get their VBC program off the ground.”

“Be sure to include staff in the incentives.”

When it comes time to share incentives with staff members, PCPs have any number of ways to do it. Which is best? Rebecca Welling believes one effective way is to link specific incentive payments to the successful performance of specific tasks. “For example,” said Rebecca, “you could offer to pay your scheduling staff $25 for every one of these high-acuity patients they bring in.” The direct connection between task and reward can be a strong incentive.

“Take advantage of friendly competition.”

Don’t be reluctant to share provider performance data within your organization to spur friendly competition. Reddy said, “As clinicians, we have a competitive drive within ourselves, and this has really motivated us to push each other to deliver quality care to our patients.” Bottom line? Money isn’t the only incentive; competition can be a powerful tool, as well. To encourage competition, Dr. Reddy said “Dashboards are our friend.” Readily accessible and easy-to-read dashboards make it simple for physicians to compare their work with their peers’.

How Vatica Health can help

The Vatica Health solution directly supports many of the recommendations made by the experts on the podcast. Vatica Health is the leading PCP-centric risk adjustment and quality-of-care solution for health plans and health systems. By pairing expert clinical teams with cutting-edge, Vatica increases patient engagement and wellness, improves coding accuracy and completeness, identifies and closes gaps in care, and enhances communication and collaboration between providers and health plans. The company’s unique solution helps providers, health plans and patients achieve better outcomes, together. With the Vatica team providing the extra resources needed to get VBC off the ground and operating successfully, physician participation is easier to enlist and sustain. To learn more, visit https://vaticahealth.com/.

How to close care gaps for patients with SDOH

By Vatica Health | December 7, 2021 | Provider, Risk Adjustment, Value-Based Care

By Shannon Lukez, chief clinical operations officer, Vatica Health

Even before COVID-19, providers struggled to close care gaps. The pandemic has only worsened the problem as some patients continue to delay or forgo care out of fear of contracting the coronavirus. In addition, there’s a significant number of patients who struggle with non-medical factors such as lack of transportation, economic stability, literacy, housing, and food insecurity which contribute to untreated care gaps and poor outcomes. Unaddressed social determinants of health (SDOH) not only leads to disparate care, it also prevent providers from optimizing performance under value-based care (VBC) programs. Why is it so hard to close gaps in care – especially for patients with SDOH?

Provider burnout. For starters, addressing SDOH is one more thing—albeit a critically important one—on an already daunting to-do list. Many providers are on the verge of significant burnout, which is being exacerbated by a shortage of resources caused by Covid-19. When faced with the patient in front of them, they’re frequently only able to address the condition prompting the reason for the visit. They don’t have the time or staff necessary to dig more deeply into the non-medical factors that could be contributing to the patient’s overall health status.

Lack of SDOH data. Many providers don’t have the data necessary to identify at-risk patients. If they don’t collect this data themselves or have access to it in some other way, they won’t know which patients are facing SDOH-related challenges. It’s impossible to effectively address these barriers without having a targeted, analytics-driven approach.

Lack of clinical and administrative support. Providers don’t have the clinical and administrative staff necessary to perform patient outreach and engagement. Many practices are still struggling to retain staff needed to perform the most basic duties necessary to keep the business afloat. Recent Covid-19 vaccine mandates for healthcare workers have only worsened the resource constraints. Tackling SDOH is an added responsibility for which many providers feel their staff simply don’t have the bandwidth.

How health plan-sponsored programs can help

The good news is that some health plans are starting to step in and partner directly with primary care physicians to help them close care gaps and address SDOH. That’s because these payers realize providers can’t do it alone.

Consider BlueCross Blue Shield of Massachusetts (BCBS-MA) that has begun to incentivize providers to address gaps in care specifically for people of color. The payer is using existing HEDIS data to identify racial and ethnic disparities and then link solutions to its current value-based purchasing model.

As part of this initiative that will begin in 2023, BCBS-MA will work with providers and employers to collect data and continue to ask members to self-identify. BCBS-MA is also using imputed data (i.e., data that assumes a member’s race based on multiple factors). It will focus on colorectal screenings, adolescent well care, severe maternal morbidity, and antidepressant medication management for Asian, Black, and Hispanic members of its commercial plans that are already attributed to its primary care-focused Alternative Quality Contracts.

The BCBS-MA initiative is a step in the right direction because it acknowledges the importance of these two elements: Comprehensive SDOH data and aligning VBC care with financial incentives. However, health plans cannot overlook a third factor that’s equally as important: Infrastructure augmentation—specifically, clinical and administrative support.

A health-plan sponsored program can help incentivize physicians to identify and address SDOH without adding operational burden. However, this type of program must not only supply data, technology, and aligned financial incentives—it must also provide expertly-trained people and clinical resources to achieve and maintain physician engagement.

To learn more about Vatica’s PCP-centric solution to improve clinical and financial performance, visit https://vaticahealth.com/.