Why is it so hard for academic medical centers to succeed in value-based care?

Academic medical centers (AMCs) excel in many ways, but struggle to succeed at delivering cost-effective care in value-based payment models. To the extent these payment models become more widespread, or mandatory, this could be a giant risk to the future success of AMCs. Many attributes of AMCs that have served them well in a fee-for-service payment system may hinder the transformation needed to succeed in value-based care. Much of the underperformance of AMCs may be explained by two core competencies that AMCs lack: the limited ability to redesign clinical workflows and inability to change their economic relationships with their own specialists and primary care providers. These limitations, in turn, flow from a combination of electronic medical record systems that lock-in existing practice patterns, compensation systems that reward volume over value, organizational structures that make it very hard to drive clinicians to change, workforces with too many specialists, and complex accounting systems. To preserve current margins in value-based care, AMCs need to reduce their cost structures and gain new skills in primary and preventive care. Alternative, AMCs may choose to eschew value-based care and raise their prices for fee-for-service to offset declines in patient volume.

Making care primary: Medicare's latest attempt at value-based primary care.

On June 8th, 2023, the Centers for Medicare and Medicaid Innovation (CMMI) announced the Making Care Primary (MCP) model, its latest attempt to transform primary care delivery for a value-based care payment system. The MCP is a decade-long multi-payer partnership with a voluntary risk-adjusted payment model for primary care organizations. It provides financial support for organizations to develop and implement a value-based care infrastructure and prospective payments per beneficiary for the delivery of primary care. The MCP consists of 3 tracks, ranging from lump-sum infrastructure payments to a fully prospective payment model with 1-sided risk. In turn, physicians need to meet a set criteria, such as quality outcomes, health-related social needs screening and referral, and high-touch chronic care management (CMMI; https://innovation.cms.gov/innovation-models/making-care-primary). While MCP is a well-planned effort, it is likely to suffer from some of the same pitfalls as prior CMS attempts to revolutionize primary care and may therefore exert unintended effects on market consolidation.

Beyond the Lab: Empirically Supported Treatments in the Real World.

Laboratory studies of empirically supported treatments (ESTs) for mental health problems achieve much higher rates of clinical improvement than has been observed following treatment in the community. This discrepancy is likely to due to limited reliance on ESTs by therapists outside of academia. Concerns about the generalizability of ESTs to patients in the community, who may have comorbid problems, likely limit rates of adoption. The present study examined the impact of ESTs delivered in the real-world for 1,256 adults who received services through an employee assistance program specializing in the delivery of ESTs. Rates of anxiety and depression decreased significantly, following treatment with an EST, and 898 (71.5%) patients demonstrated reliable improvement. Even among patients comorbid for depression and anxiety at baseline, over half reported reliable improvement in both disorders. Findings suggest ESTs can be effectively delivered outside of academic RCTs. However, additional research is needed to understand and overcome barriers to disseminating ESTs to the broader community.

Bending the curve through health reform implementation.

In September 2009, we released a set of concrete, feasible steps that could achieve the goal of significantly slowing spending growth while improving the quality of care. We stand by these recommendations, but they need to be updated in light of the new Patient Protection and Affordable Care Act (ACA). Reducing healthcare spending growth remains an urgent and unresolved issue, especially as the ACA expands insurance coverage to 32 million more Americans. Some of our reform recommendations were addressed completely or partially in ACA, and others were not. While more should be done legislatively, the current reform legislation includes important opportunities that will require decisive steps in regulation and execution to fulfill their potential for curbing spending growth. Executing these steps will not be automatic or easy. Yet doing so can achieve a healthcare system based on evidence, meaningful choice, balance between regulation and market forces, and collaboration that will benefit patients and the economy (see Appendix A for a description of these key themes). We focus on three concrete objectives to be reached within the next five years to achieve savings while improving quality across the health system: 1. Speed payment reforms away from traditional volume-based payment systems so that most health payments in this country align better with quality and efficiency. 2. Implement health insurance exchanges and other insurance reforms in ways that assure most Americans are rewarded with substantial savings when they choose plans that offer higher quality care at lower premiums. 3. Reform coverage so that most Americans can save money and obtain other meaningful benefits when they make decisions that improve their health and reduce costs. We believe these are feasible objectives with much progress possible even without further legislation (see Appendix B for a listing of recommendations). However, additional legislation is still needed to support consumers ­ including Medicare beneficiaries ­ in making choices that reduce costs while improving health.