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VBP Toolkit: Section III. Go live with VBP model(s)

Overview

Implementing VBP involves many different facets of operations – both for you and your payers.

You may have already dipped your toes into VBP arrangements, either willingly or because your payers have incorporated some LAN Category 2 Alternative Payment Model components in their standard provider agreements. But to truly move from volume to value and transform care delivery is a journey. Consider your size and tolerance for financial risk when planning your VBP journey.

Section III. steps

Success in VBP arrangements is shown by improving quality for patients, cost-effectiveness for payers, and both patient and provider experiences. Being paid based on value, as opposed to volume, presents providers with flexibility to care for patients with a team-based approach.

To maximize this flexibility and be successful under VBP, you may want to institute or encourage certain operational capabilities such as:

  • Open access, allowing for same-day scheduling of patients
  • Ability to accommodate patient appointments or phone calls after-hours and on weekends
  • Meeting patient response and/or scheduling time standards
  • Sufficient processes for obtaining release of medical histories to and from behavioral health (BH) providers
  • Adequate behavioral health support to promote BH integration (such as through contracted mental health and substance use services, or qualified behavioral health care managers).

Green ribbon icon representsBest practice

  • Like primary care practices across the country, West Hills Healthcare was hit hard at the beginning of the pandemic. To respond to the challenge, the clinic created protocols for care that were so successful the management team realized protocols could be created for basically everything. These protocols facilitated implementation of operational changes that support VBP success. One example is the training and support of medical assistants to run the annual well visit schedule and work at the top of their license. Implementation of this new protocol allowed the clinic to get patients in for well visits even when provider schedules were full with COVID-19 related care.
  • The metrics team, including an EHR super user, regularly conducts a deep dive into their EHR to set clinical focus areas, runs lists to identify patients who need to be seen and communicates the right place for documentation. The team prioritizes making it easy to improve care, such as creating a pop-up in the EHR for every patient with diabetes that providers and front desk staff see.
  • Adding a behavioral health provider and a care manager was another operational change to support success in VBP arrangements. Yamhill Community Care Organization, the local Medicaid payer, recognized the importance of integrated behavioral health to improving care for members and supported West Hills Healthcare with resources to provide these services. This investment grew when the clinic joined CPC+.

Predictable and flexible payment

More advanced VBP models offer providers more predictable and flexible financial arrangements to support and maintain systemic changes in how care is delivered. For example, moving from a Category 2C Pay for Performance model to one with shared upside (and then downside) risk offers provider entities the greatest opportunity to truly invest in and transform delivery of care. Advanced VBP models more significantly restructure payment for provider entities to better enable and support delivery system transformation.


Green ribbon icon representsBest practice

  • Participating in Portland Coordinated Care Association, an independent practice association (IPA) with over 140 primary care providers and specialists, has been instrumental for Northwest Primary Care in partnering with payers, who share the same quality and utilization goals, in contracting around VBP arrangements. The IPA negotiated an LAN 2C pay for performance arrangement with one large payer focused on increasing quality to reduce ER visits, hospital admissions and readmissions. This payment model was built on the 10 year-long Center for Medicaid and Medicare Services Comprehensive Primary Care Initiative and Comprehensive Primary Care + programs which ended in 2021, supporting the clinic to hire and retain care coordinators, case managers, clinical pharmacist and quality improvement specialists hired during this time. These team members, extensive data analysis to identify patients and services needed, and focused outreach to patients resulted in achievement of quality goals and cost savings for payers.
  • After successfully implementing the 2C model the IPA members felt ready to take on a more advanced VBP model. The IPA and payer negotiated an LAN 3A shared savings arrangement with total cost of care (TCOC). For Northwest Primary Care the engagement of a multispecialty clinic in the VBP arrangement and partnering with payers who understand the value quality groups bring to their patients is key to success.

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​"With primary care and specialty care providers in the VBP arrangement everyone is on the same page and focused on the best care for each patient."
Charlotte Flood, MHA, CMPE
Chief Executive Officer
NW Primary Care Group PC​

Clinical transformation

To be successful with VBP, provider entities need internal staff dedicated to transformation, and may benefit from engaging outside expertise for transformation and quality improvement. Identify clinicians and operational staff that understand and can explain best practices around performance and prioritize specific opportunities for improvement in a VBP context. Provider entities and clinicians may need support on how to:

  • Develop, review and interpret reports in a VBP context.
  • Prioritize and track opportunities for performance improvement.

Many provider entities and clinicians will benefit from consultative support early on to learn how to operate effectively under a VBP arrangement. Provider entities can find valued partners from payer and provider associations or consultants, who might offer provider entities hands-on support delivered to individual provider organizations (or in a group setting with regular meetings) to discuss trends and suggest potential action steps.

Some payers may offer training programs for their network providers to learn the skills for success in value-based payment. Training programs can range from care management webinars to leadership development strategies.


Green ribbon icon representsBest practice

CareOregon has established a Technical Assistance team that consists of staff skilled EHR usage, nurse care managers, and other support staff, The TA team can assist practices in everything from coaching nurse care managers on caseload volume, to assisting providers in outreach telephone calls to patients.​

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Payers, medical associations, consultants and government entities can provide technical assistance to support providers’ implementation of VBP models. Ask your payers if they have resources to support your success in VBP. OHA developed a series of webinars for providers focused on increasing readiness for VBP and taking advantage of the additional flexibility VBP models offer for innovatively redesigning care models.(8​)


Green ribbon icon representsBest practice

InterCommunity Health Network CCO (IHN) supports their primary care practice partners with technical assistance (TA) focused on successfully meeting Patient Centered Primary Care Home standards, which can include VBP. To accomplish this IHN contracts with Creach Consulting Group (CCG) to provide TA at no cost to their primary care network. CCG supports practices where they are and what is on their agenda to help them progress on their transformation journey.​

CCG works with primary care practices at all stages of readiness for VBP, from struggling with timely access to care, integrated behavioral health, or reaching quality metric benchmarks to addressing burnout and improving staff engagement.

IHN is committed to helping their practices be successful and recognized that a third-party TA consultant can engage with practices differently than a payer. Working with CCG, practices have increased their ability to participate in VBP arrangements and IHN has developed better relationships with its primary care practices.​


Footnotes

8. Oregon Health Authority - Value-Based Payment
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Quality measures are a key component of any VBP arrangement. Important questions to consider include:

  • Are the measures aligned with the provider’s VBP and clinical goals?
  • What data are needed to meet measurement requirements? Will the provider need to provide supplemental data?
  • What kind of data sharing is required? Does the measure set require changes to my EHR?
  • How many and which measures are tied to the financial incentives or payment arrangements?
  • To what extent are different payer VBP measures and benchmarks aligned?
  • How are provider performance benchmarks established?
  • Does the payment arrangement recognize both achievement and improved performance?
  • Are measures weighted equally in terms of financial calculations in the payment arrangement?
  • Are incentives tied to provider and/or payer activities or investments in delivery system reform?
  • How are performance benchmarks established?

Setting performance benchmarks and improvement targets

There are multiple approaches payers may adopt to set performance benchmarks and assess provider performance on quality and patient experience measures. For example, a VBP arrangement may measure your performance to targeted metrics based on:

  • A specific, absolute performance threshold (sometimes referred to as an external benchmark). Standardized HEDIS measures are often reported in percentile rankings to a specific benchmark.
  • Relative performance to other providers/peers.
  • Improvement targets relative to your own past performance may evaluate a provider entity’s absolute percentage point improvement, gap reduction between the target and the performance rate, or achievement of statistically significant improvement to define VBP improvement benchmarks.

Green ribbon icon representsBest practice

  • Six years ago, PacificSource Community Solutions – Columbia Gorge CCO began partnering with primary care providers and Central Oregon Independent Practice Association to annually select an aligned set of quality improvement measures (QIMs) for use in the capitated VBP arrangement. Providers convene at 7 a.m. three times over six weeks to engage in an iterative process to select a subset of the CCO quality incentive measures for focus in the next year. The process starts with reviewing the prior year’s selected metrics as well as overall performance data for all QIMs, eliminating current-year measures that are too easy or too difficult, discussing the remaining current-year measures and selecting a small set for all primary care providers.
  • The CCO invested time upfront and continues to do so to build relationships and trust with providers. This work and time invested in organizing the annual process, has resulted in a partnership that improves the quality of care members receive and reinforces the philosophy of improvement. To promote coordination, PacificSource has structured the performance-based payment component of the VBP model such that if the CCO meets the OHA benchmark for the selected metrics all participating providers receive the quality incentive. Over the six years of the model all providers have received the incentive payment nearly 100% of the time.

Resources

Webinar: Performance benchmarks for VBP models (8/24/21) Slides / Discussion guide / Recording​
  • This CCO-focused webinar discusses considerations for developing performance benchmarks for population-based and episode-based VBP models.
Performance Measures Criteria
American Academy of Family Practice (AAFP)
  • Summarizes the AAFP principles and criteria for selecting performance measures in VBP.
  • Key points: Performance measures may overlap with quality measures that accelerate internal clinical improvement.

Performance gates and ladders

Some VBP arrangements may include performance measures as​ a "gate." A gate is a minimum performance benchmark that a provider must meet or exceed for the provider to receive a specific incentive payment (such as shared savings), or in some cases, even to participate in the VBP payment.

In addition, VBP arrangements may include a performance "ladder."​ In VBP models using a performance ladder the payment amount, or the amount of savings or loss for which a provider is accountable, could vary based on quality performance. A high-quality performer might be able to share in a greater proportion of savings it earns, or be responsible for a smaller percentage of losses it incurs. Similarly, the quality performance of a provider in an episode-of-care model might influence the gain/loss distribution for shared risk arrangements, and/or qualify a high-performing provider entity for a separate bonus. In these types of VBP arrangement, quality performance plays a very important role within the payment model.​​​

Performance measurement is central to VBP. Payers select metrics and set benchmarks and improvement targets. It is common to have little to no overlap in metrics across payers. To the extent possible, it is beneficial if you can negotiate for common metrics.

"When quality measures (QMs) are thoughtfully created and implemented, they can enhance medical care by focusing clinical efforts toward specific beneficial health outcomes. QMs can also, however, be overused. …when health insurance plans measure the performance of overly long lists of QMs in their contracts … clinicians' attention is diverted away from patient-centered, outcomes-based care and toward "check-the-box" care, with time-consuming administrative tasks and data submission efforts. Similarly problematic are rarely used QMs, particularly QMs created and used by a single insurance plan."(9)

Green ribbon icon representsBest practice

In 2017, Massachusetts convened a volunteer body of consumer advocates, health insurers, provider organizations, quality measurement experts and state agencies to design an aligned quality performance measure set to be used by state public payers and by commercial market payers in value-based total cost of care provider contracts. The Quality Measure Alignment (QMA) Taskforce ultimately recommended a mix of “Core Measures” (measures to be used in every contract) and “Menu Measures” (measures to be used at the discretion of individual payer/provider contracting partners). Since that time the QMA Taskforce has annually updated the measure set. For 2023, it adopted six Core Measures and 23 Menu Measures. Voluntary adherence to the aligned measure set has been high; Massachusetts payers report that over 80% of their contract measures are in the aligned measure set. This is impressive given that many provider contracts are multi-year, and the measure set changes a little each year. During 2021 and 2022, the QMA Taskforce added health equity-focused measures, and developed health equity data standards and a framework for introducing accountability for health equity into value-based contracts. For more information, visit the MA Aligned Measure Set website.​

Design for equity by including equity-focused measures

  • The National Committee for Quality Assurance (NCQA) introduced race and ethnicity stratifications to five HEDIS measures, such as colorectal cancer screening and controlling high blood pressure.(10)
  • The National Quality Forum (NQF) has identified 19 disparity-sensitive measures, such as depression response at 12 months in primary care and functional status assessments for congestive heart failure in cardiology.(11​)
  • Stratify any metrics you can by REALD and develop a QI plan including addressing disparities.

Keep quality improvement efforts to no more than 10 metrics at a time

  • Review and modify this top ten list at least annually depending upon the opportunities for improvement and for additional VBP earnings.
  • Specifically identify metrics where you see significant variation between the highest performing providers and the lowest performing providers, and metrics where your organization overall is performing below VBP benchmarks.
  • Take advantage of technical assistance, webinars and trainings related to sharing best practices, clinically and operationally.

Establish processes and tools that measure quality of your organization and individual clinicians

  • Use data and VBP performance dashboards to identify and act on performance when it differs from established VBP targets.
  • Identify areas where variability in clinical practice exists within and across your organization, and where gaps between current practices and knowledge can be closed.
  • Multiple levels of VBP dashboards can be created depending on available resources, payer support, the size and complexity of the provider entity and the breadth of your VBP arrangements. Different levels of VBP dashboards could include:
    1. provider entity performance overall and across payers,
    2. practice-level dashboards and
    3. peer clinician-level dashboards.

Focus on metrics used in VBP arrangements. Examine how you can offer clinicians and practices ready information to understand care gaps at the point of care or during morning routines so that progress is being made toward improving outcomes when patients are seen. Consider changes to your information technology approaches and your manual processes to support improvement in targeted VBP metrics.

VBP performance meetings

  • Establish regular, substantive meetings on VBP performance and provide transparency on performance regarding the extent to which each practice/clinician is meeting expected performance levels for quality, efficiency, or other priority measures.
  • Use internal and payer data, including available VBP performance dashboard(s), to support these discussions.​
  • In advance of these VBP meetings, identify specific performance areas to be discussed, the process and timeline for reviewing performance in the future and specific performance goals.
  • Set annual improvement goals, including baseline, mid-cycle and final evaluation periods, to track improvement gains at the provider entity and clinician levels.
  • Schedule and structure VBP performance-focused meetings with key practices/clinicians and senior executives on at least a semi-annual basis.
  • Consider the size of your provider entity and how often senior leaders will meet with practices and/or clinicians, individually and in small groups, to discuss VBP performance expectations, challenges and trends.

Think creatively about how to develop and implement incentives and supports to reward high-performing clinicians and practices. Create non-financial and financial incentives that clinicians and practices can see relatively quickly, even if payer VBP financial incentive payments have a significant lag. One example of a non-financial incentive could be monthly awards to recognize practices with increased reporting of targeted preventive and primary care. In addition, encourage practices to offer suggestions for how to allocate VBP rewards, including ranking priorities for re-investing VBP earnings to increase your collective ability to continue to improve the delivery of cost-effective, quality care.


Footnotes

9​. Rubin I., Israel J. (2022) The Case for Aligning Quality Measurement​, Health Affairs Forefront

10. HEDIS 2022: See What’s New, What’s Changed and What’s Retired​

11​. CQMC Workgroup Meeting Summaries​

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 Top of Section​​​

Once the VBP model is implemented, it’s important to evaluate your performance and work with your payer to adjust the contract if needed. Negotiate this capability upfront in your contracts, such as negotiating the first year as pay-for-performance (LAN category 2C) to watch the data. It’s important to look at prior time periods to model future years.

The troublesome claims lag

A common challenge to understanding your performance on HEDIS measures is the claims lag. The claims lag is most pronounced in hospital data because of the billing delay. Other examples of challenges include being unable to provide the data the payer wants, or not having enough members for a given measure. If these challenges or others arise, you need to be able to make modifications, such as evaluating changes for year three of the contract in year two.

You could ask for fewer HEDIS measures, exclude some or substitute, or negotiate partial payment for performance improvement if you realize there is no way you can meet the quality target. You can also negotiate on the targets. Payers can help you understand where you are in quality by providing mid-year reports. This is not possible on the financial side because of the billing delay.

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Once you have implemented a successful VBP model it is time to scale it up by engaging additional payers. The VBP Compact Workgroup is working to facilitate this by identifying a short menu of recommended VBP models. The first model developed will be a primary care model.

Even when payment models differ, aligned quality metrics can make adoption easier. To the extent you can, work with your payers to established aligned measure sets.

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