Andrew L Concoff, MD, FACR, CAQSM: Value-Based Care

Rheumatology Network sat down with Andrew L Concoff MD, FACR, CAQSM, Chief Value Medical Officer at United Rheumatology. We focused our discussion on value-based care, including the benefits, collaborate approach to working with payers, the revenue and cost savings, and how value-based care can support routine and consistent health visits.

Andrew L. Concoff, MD, FACR, CAQSM

Rheumatology Network: Hi, Dr Concoff. Thank you for joining me today.

Andrew L Concoff, MD, FACR, CAQSM: Hi, it's nice to see you.

RN: To begin, what is value-based care?

AC: So, value-based care is a healthcare delivery model where physicians or hospitals get compensated get paid based on delivering outcomes that are measured in a programmatic fashion.

RN: How is value-based care different from fee-for-service models?

AC: So, this is the critical thing for everybody to understand about value-based care. In fee-for-service, the same groups, hospitals, and physicians get paid for what they do to patients. That is, how many colonoscopies they do, in our case, how many injections they do, how many consults they do, and it really values efficiency but it makes no comment about quality. And the problem with that is that the outcomes are not typically measured. So, in value-based care programs, we have to come up with a metric, some way of measuring how patients have done. And we also measure costs. And this is a critical part of this puzzle. So, what I recommend is that we take it out of a healthcare environment and think about an analogy. If we think about grocery delivery services, let's say that we're interested in getting apples to customers. I like apples, honey crisp apples, although they're pretty fragile. The idea is it during the pandemic, when I would order them, oftentimes I get the worst, bruised up apples at the end of the day. And yet, the person who delivered them to me was paid the same thing. And likely those folks weren't paying much attention to the apples; they were grabbing them going and seeing how many people they get delivered to. In a value-based scenario, the analogy would be, let's develop an apple damage index. And let's decide where we measure that. Namely, when I get them out of the bag at home, not when they're being driven to me or purchased by the folks that do that. And the idea here would be I want quality. I want those apples to be cared for, I want them to be in excellent condition. I'm not trying to commoditize healthcare, and obviously patient outcomes are more important than my apples. But the point here is that what we ought to be paying for in healthcare is for individual patients to be cared for in an excellent way that preserves their health and well-being and that the cost of doing that should be measured. But we also should be measuring each patient's journey and coming up with ways that we can formally assess how that care has affected them favorably or unfavorably. Not just how many times they were seen or how much was spent on them, but how that affected them so that we deliver high quality care that results in good outcome.

RN: What are the revenue and cost savings of value-based care?

AC: The idea here is that if we provide high quality care, we should both be delivering these health outcomes that we've talked about, and not doing low-value care. That isn't helpful to the patients. We should be choosing medications that are just as effective, but perhaps of lower price. The idea is if a doctor does a nice job of managing their responsibility to the healthcare system, there might be less cost spent and better outcomes. That's the only way these programs really work. And if the if the costs are lower than compared to what would have been in a fee-for-service environment or compared to a control group, there's a cost savings. And some of that savings is shared back to the clinician or the hospital that's engaged in the program. So that's where the revenues come for the practice. And the savings obviously has to work for everybody. It has to be that the health plan saves money, if they're involved, and it has to be that the hospital or, in most cases, the clinicians also make more money by doing this. It's challenging because the clinicians have to make changes to their workflow and still take care of all these others. In my prior example, they still have to deliver bananas, even while they're trying to deliver apples, and get measured on delivering apples. They still have to be doing the rest of their job, in our case, give a value-based care program in rheumatoid arthritis while still taking care of lupus patients. And so, you have to attend to additional factors in the clinic and make sure that those workflows are not interrupting the care that you're providing to others. And this is what creating these programs, which is my job. It's what we have to be cognizant of as we create these programs that we don't interrupt the daily workings of the clinic with the programs we create.

RN: What are the benefits of value-based care and how does it allow for personalized patient care?

AC: There are several benefits in a successful value-based care program. You could say that there's the opportunity to lower costs of care, you could say that there's the opportunity to improve outcomes. And really, that's where I would focus that it really puts a premium on delivering outcomes for individual patients. And this is what precision medicine is all about. When I go to see the doctor, I care about how I am going to end up doing. I don't care about the average patient; I don't care about the typical patient. And I don't particularly care about the doctor seeing a ton of other patients. I want my care to be excellent and my outcomes to be excellent. And that's really what these value-based care programs are about. It's about assessing the individual and assessing the individual's journey and the individual's response. And in rheumatology, we're still in the process of adapting this treat-to-target model where we're assessing patients before and after an intervention and response and how they respond on an individual level to guide changes in their care. Unfortunately, this has not been as widely adopted yet in the United States because we know that it yields better outcomes and lower costs for the system. And right now, I think a critical thing to understand about this is that those doctors are doing a great job, or not getting paid for doing a great job they're doing. They're getting paid the same if they do great jobs or not. You could say that word of mouth can increase how busy they are in their practice, but at least formally, the way that they're being compensated is not about the quality of care they deliver. Any doctor that's doing a great job out there is doing it because they believe in that because of the good graces of their heart. And because it's generally good for business, this value-based care approach directly compensates doctors for generating good outcomes.

RN: How does a collaborative approach to working with payers benefit practices and patients?

AC: I worked in a sort of adversarial relationships for 20 years with payers before I came to this value-based approach and got more and more enamored with it. Now that's what I do all day. It used to be that it was sort of like the Hatfields and the McCoys in my clinic where we felt like the insurance companies were doing it to us again; the problem was that that wasn't a very productive way of interacting and it didn't actually work when you think of it as a zero-sum game. That is, every dollar that I make is $1 that the insurance company isn't making. That's sort of the way that we looked at. The fact of the matter is in our healthcare system, there's a different role that a health plan has and that clinicians have and the priorities are different. What these value-based care programs allow is to create a Venn diagram of our needs on the clinician side, on the health plan needs, and overlap those and create programs that bring the best of the intentions of both sides to bear on the patient care and brings patients along. And so the opportunity is to build relationships and build understanding between clinicians, or clinician groups like United Rheumatology, where I work, that creates these linkages between health plans and clinicians. And the more that we work together, the more that we understand one another, the more that we recognize opportunities to work together. You can think of, for instance, in this fragmented healthcare landscape, the United States, unlike a lot of European countries, I'd like to think of these value-based programs as a data bridge, that that on the one side of the river we're building, that we have the clinicians building a bridge, and the data is the steel they use to build that bridge. What kind of data is that disease specific activity measures, for instance, like a CDAI in rheumatoid arthritis? And we know how active the patient's disease is at a given time, but the payer has no idea about how a patient is doing. And then there's this big gap in the middle of a river on the other side. They're building a bridge toward us in these programs, and their data, their steel, that they're building that bridge from his medical claims, data, claims data, that they have these other forms of information that we don't have access to. And in our healthcare system, typically, there's been a huge gap in between those 2 data sets. And what these programs do is they link them together like a bridge, and we share information. On the other side of the fence, the health plan shares information. And only by sharing that information and bringing that data together, can we determine what the best approaches are from an outcome perspective for the patients. And from a cost of care perspective for the system?

RN: How does value-based care support routine and consistent health visits versus urgent appointments?

AC: In some situations, it might not. It depends on the way that the program is developed. And this is where a group like United Rheumatology, who has now extensive experience in generating and creating and negotiating these value based arrangements, can help to avoid some pitfalls that might get in might get in the way of these programs. For instance, if there's too much reliance on the cost component of these programs, and if we don't robustly assess the outcomes, there's a risk of warehousing patients. That is to say, if you took all the patients with rheumatoid arthritis, and just put them in an airplane hangar for a year, the cost of care would go down to some extent. That would be an absolutely travesty for the outcomes of the patients. I was being facetious about how we take care of the patients, but the idea here is we have to robustly value the outcomes in these programs. Because if we don't, then if it's all about the cost of care, then then we can end up doing harm to the way patients are managed. So, it's about negotiating these programs. Now in terms of routine care, I think it's really important that we keep track of these patients. And so, when we have an arrangement with these health plans, we become aware of things like the fact that some percentages of patients don't have any follow-up schedule. They may have lupus, they may have scleroderma, systemic sclerosis, and they don't have a follow up on the books. And the only way we become aware of that is we get a list of patients from the health plan and we look to see when they're scheduled. And that's sometimes a difficult thing to keep track of at the practice level of all these patients and it allows us to focus in on subpopulations and to determine what's happening with those patients to follow up with them and to catch for those that have been sort of lost to follow-up,

RN: Is there anything else you'd like our audience to know before we wrap up?

AC: Sure. I mean, I think this is a critical moment for value-based care in rheumatology. And the reason that I say that is that we prescribe the most expensive drugs on the planet. That is to say, specialty drugs are expected to have gone up by 78%, in the 5 year period, ending in 2022, in terms of their costs. That greatest contributor to that specialty drug class are the anti-inflammatory drugs that we prescribe; they make up 35% of the overall costs of specialty drugs: 6 of 10 of the most costly specialty drugs or drugs we prescribe. And critically important here is that Humira, without much fanfare, in 2019, became the first ever drug that cost a health plan $100 per member per year; that is for everyone in their health plan, not just those taking, but everybody in in their coverage. It costs them $100 per member per year just for Humira. And I think the important thing to realize about that is that there's this opportunity now, because Humira is going to go off patent in 2023. And we have this opportunity to create a new system that links the cost of these drugs to the value they create for individual patients the outcomes they create. And the only way to do that is with value-based care programs. And what this means at the clinician level is that they that we have to measure outcomes routinely on patients in order to participate in these programs. Traditionally, in this country, we went by a Gestalt-based impression of how someone was doing. So, when a patient, for instance, with rheumatoid arthritis came into the clinic, I would assess them in my clinic, I would determine how I thought they were doing. And I would make decisions just based on my impression of how they were doing. Now we have standardized instruments that are not perfect but have been demonstrated to improve outcomes. It's really important that we capture that data. Another way of thinking of this is when I was in medical school, they said if you don't document something in the medical record, it didn't happen. I think we're moving quickly toward a period here where if you don't capture data, a disease specific outcome measured from a visit with a patient, it's as if that didn't happen either. And so, we need to get better at incorporating these outcome measures into our workflows into our electronic medical records (EMRs) to make it easy for them to be captured. We need to make it smoother to capture that doesn't interrupt workflows. But once we do that, we need to be consistent about that kind of data capture. And this is critically important for private practices across the country. So, one of the things that we've said in United Rheumatology lately is that we recognize that infusion revenues, which are a big part of 30 to 40% of the revenues that are private practice, that they're they are going down because about 70% of the infusible drugs, the price of those has finally started to come down. Now you could say that that's a good thing. For instance, the price of Remicade decreasing by 30%. But that means that that's less revenue for providing those infusions at the practice level. And while those infusion revenues go down, that threatens the viability of a private practice in rheumatology. And furthermore, the self-administered drugs are not going down. In fact, they continue to go up. So private practice needs to come up with other revenue opportunities. And these value-based programs represent a tremendous opportunity for practices to diversify their portfolio in the way that we talked about investing to have a different revenue stream that are not in jeopardy to the same extent that the infusion revenues are and not lose the revenue that they've had from that. And I think it's important to understand, finally, in wrapping up, that when it comes to value-based programs, there, there, there are different levels of revenue, opportunity and different levels of risk in value under the umbrella of value-based care. So, at on the shallow end of the pool, if we think about it, you have pay for performance programs. And if you have shared savings programs where there is no risk to the practice, if you deliver good outcomes, if you deliver lower costs of care, then you get to share in some of that some of the windfall from that. As we start to get to the deeper end of the pool, we have partial risk arrangements where the hospital or the practice for the clinician has some skin in the game and could lose money if they choose the wrong kind of program. And then the deepest end of the pool is the full risk program, where you really have to have your analytics down before that makes sense. But the idea here is that one of the benefits of membership for a private practice in a small private practice in rheumatology in this country. One of the benefits of membership in a group like United Rheumatology is that we're creating these value-based programs to link together it what maybe a solo practitioner, you know, in Topeka, Kansas with either local or national health plans in a way that hasn't been adopted, robustly across the country. Thus far, there's a much greater percentage of hospitals and large medical groups that have adopted value-based care programs. And the problem is we don't want the smaller practices, the way rheumatology is typically practiced in this country. We don't want them to be left behind in this. I jokingly say the value-based care bus is leaving. We better get on because I think this is a critical moment, as we've talked about in in the development of value-based care and rheumatology.

RN: Dr Concoff, thank you so much for speaking with me today. I really appreciate it.

AC: Thank you for having me. I've really enjoyed talking with you.