Creating a Sustainable Clinical Model

With traditional healthcare delivery transformed by technological advances, market disruptors, and alternative sites of care, health systems need to adjust their clinical models to stay afloat and meet their mission of serving their communities. This was a key theme conveyed by industry leaders at the 2024 Guidehouse Medicare Advantage Summit during its “Creating a Sustainable Clinical Model” panel.

The summit, held in Washington, D.C., was convened to build connections among healthcare leaders, share solutions they can adopt to improve health system performance, and offer guidance for policymakers grounded in real-life experiences. In attendance were health system CEOs, CFOs, and COOs, along with senior executives responsible for payer strategies, revenue cycle management, population health, ambulatory care, and value-based care.

Panelists for the sustainable clinical model session included:

• Mike Flammini, chief business development officer for Privia Health Group—a technology-driven, national physician enablement company that collaborates with medical groups, health plans, and health systems to optimize physician practices, improve patient experiences, and reward doctors for delivering high-value care in both in-person and virtual settings.
• Chris Stanley, MD, president of Populance—a population health organization that’s wholly owned by Henry Ford Health and designed to support doctors, hospitals, and health plans as they care for patients and communities, especially those with polychronic conditions.
• Ben Zaniello, MD, chief medical officer for Best Buy Health, which enables care at home by providing end-to-end solutions that allow people to get well, stay well, and age well in the comfort of their own homes.

“We understand that the prolific use of prior authorizations causes delays in care,” said Tenney, an experienced attorney and small business owner who serves on the House Ways and Means and Science, Space, and Technology committees. “Between the paperwork and haggling with insurance companies, the administrative burden significantly contributes to your costs. We’re going to be doing a joint bipartisan effort with Energy and Commerce to strive for one cohesive solution.”

Carter, a pharmacist and House Doctors Caucus member who serves as chair of the Domestic Pharmaceutical Manufacturing Caucus, agreed that legislation is needed to ensure providers can focus on caring for patients.

“We need to relieve you of the paperwork burden, having to work weekends just to catch up,” added Carter.

Simplifying and Standardizing at Scale

To achieve clinical model sustainability, panelists said health systems need to integrate and capitalize on real-time, actionable data, as well as pursue innovative ways to enhance access, caregiver experiences, and the patient journey.

David Burik, partner and Guidehouse Center for Health Insights leader, added that all those focus points should be viewed within the lens of “The Three Ss”: simplify, standardize, and scale.

“Healthcare is needlessly complex; we’re our own worst enemy,” said Burik. “You can’t scale if you don’t simplify and standardize. You need to create a system instead of a collection of assets.”

Panelists agreed that the ideal goal for most health systems is to develop an optimal clinical model that can be standardized across all payment types.

“Many times, organizations will try to tailor their process flows or outcomes or analytics around each individual contract, but we’re trying to standardize the care provided regardless of payment type and make sure physicians don’t have to look at the Epic contract or member ID card,” said Stanley. “The challenge is knowing when to use people capabilities versus using tech and analytics so that we’re using lower capabilities for lower need and higher for higher risk.”

Access and the Patient Journey

Zaniello, a practicing infectious disease physician, said that Best Buy Health’s innovative in-home monitoring model is helping improve access, convenience, and data-driven clinical excellence.

“Instead of primary care offices taking appointments for data collection such as blood pressure readings, we can move that into the home,” he explained. “Our Geek Squad health agents make sure the WiFi works in the home to help people manage their health. We facilitate this for many health systems across the country that have access issues or want to create a better care experience.”

With telemedicine, subscription-based care, commercial clinics, and asynchronous options enabling more consumer-driven communication and care on demand, panelists said that health systems must adapt and be nimbler so that they can maintain clinical quality standards while remaining competitive and not losing patients to these alternative care models.

“The patient-doctor relationship must be strengthened, but the challenge of any small practice is staffing and being available after hours,” shared Flammini. “With Privia, everyone is on a common, interoperable workflow, and we’re creating convenient touch points. Instead of going to the ER, our patients can see a virtual care Privia physician—so that care is kept ‘in the family’—and then we make the connection to their primary care physician within 24 to 48 hours.”

When it comes to access issues and Medicare Advantage specifically, Zaniello has a somewhat distinct perspective compared to that viewed through the traditional clinical model lens.

“Medicare Advantage patients often qualify as early targets for innovation,” he noted. “We need to drive more access that allows continuum of care opportunities for higher quality and reimbursement. If patients are being siphoned off to easier care but disconnected from their PCP, it undermines our total healthcare system.”

Improving the Caregiver Experience

For Privia, providing operational and tech assistance so that doctors can focus on caring for patients is a more enduring way to facilitate quality care across the continuum while optimizing the clinician experience. Its physician-led model features a common platform across fee for service and value-based care contracts, with technology and field staff handling revenue cycle, EHR, and payer contracting. Privia doesn’t employ doctors but instead offers them 3- to 5-year contracts and enjoys a physician retention rate of 98%.

“Our idea was always very simple: let’s keep every practice as they are,” said Flammini. “We are a true multispecialty group that’s built to last, with a culture of accountability because each physician has a stake. They own this group and will take it seriously by continuing to work for themselves but also for each other as physician partners. We’re embedding resources that help them every day, and when they have a big issue, they come to us. That creates an incredible level of engagement. It’s the culture…there’s value and technology and feeling part of something bigger. They’re in control of their destiny.”

Stanley said that having a more robust focus on population health is one of the best ways to enhance the caregiver experience.

“We feel strongly that risk capture should be clinically driven, and the benefit is that you do well on cost of care at the end,” he said. “When you’re truly committed to the community long-term, it’s more about preventing illness through attention to social determinants of health and other elements.”

He shared the story of a patient who improved his poorly controlled diabetes in just four months after enrolling in Henry Ford Health’s Diabetes Care Connection.

“Many patients would benefit from interventions like this, but we have to scale up resources and funding,” he noted. “Saved dollars from value-based payments allow you to make those types of investments.”

Flammini added that another way to support physicians in doing what they’re trained to do without having to think about reimbursements is to hire the best actuaries and obtain the most meaningful datasets to ensure that pricing is as accurate as possible.

“We believe care management is best delivered in the physician’s practice,” he said. “We manage over a million lives across 4,300+ providers as one of the largest population health companies, so we’re not dogmatic about the downside risk of working across 100 value-based payment arrangements. We try to make smart decisions about when to do that, and it always starts with pricing. With pricing models in value-based payments, if you can’t price your product right, you have no chance of winning. You need a tremendous dataset so that you’re positioned well and not running headfirst into risk.”

Better Use of Data and Tech

Zaniello emphasized the importance of creating avenues for greater access through technology while ensuring that the right data—and the right amount of data—is flowing into the EHR and available to providers without overwhelming them.

“Providers are expected to manage someone with 15 comorbidities in 20 minutes, but they can’t do that if specialist appointments are scheduling six to nine months out,” he said. “By handling continuous glucose or blood pressure monitoring in the home instead of sending in a nurse, we’re creating a way for specialists to take in more patients. But then you have to ensure that the results are flowing into the EHR so that the data is accessible to support clinical decision making when and where it’s needed.”

Flammini also noted that the reimbursement shortfalls so common to Medicare Advantage and other value-based contracts are often caused in part by tech asymmetry between payers and providers.

“We’re trying to settle payment on flawed information such as attribution files, which are often wrong,” he said. “We’re trying to level that and help providers clean things up for accuracy of payments, starting with the basics and working up to cost and quality and patient satisfaction metrics. We spend a lot of time creating the best possible dataset knowing it will always be a little inaccurate…some are better than others but are still struggling to reflect the performance to providers that shows the outcome.”

When it comes to determining how much and which types of data should be transmitted without overwhelming providers, Flammini said it’s essential to involve providers in the decision-making.

“Our data and tech strategy is governed by the doctors,” he said. “We ask about 20 physicians from across the country among different practice sizes and specialties to lead our information strategy. We listen to them because we’re trying to understand their daily workflow and learn what information is relevant to them before, during, and after patient visits so that we can properly put that information into the EHR at the point of care. It’s a huge information overload challenge, with there being too much data or having it in the wrong format. It’s a constant journey.”

Zaniello agreed and said that it’s a continual learning process to find the balance.

“If we’re measuring oxygen saturation readings for someone with congestive heart failure who’s sleeping, and the tech is pinging providers every 10 minutes letting them know the patient is desaturating, you need to reset your bar for what is appropriate as you learn how to use the tech,” he said. “We’re getting thousands of data points in a day, and because of that we’ve had to figure out how to create a signal in the noise and where to put the data. We’re working with Epic to be sure that we’re pushing the data to the right space in the EHR and that it’s accessible to providers in the most sensible and actionable way.”

He added that having windows into patients’ real lives through in-home monitoring can help PCPs with medication management.

“What patients are taking is often so different from what they’re prescribed,” said Zaniello. “We’re helping get more visibility into what’s happening beyond the walls of a doctor’s office or clinic. As the saying goes, the most expensive medication is the one that’s prescribed, filled, and not taken.”