AHA Reviews Value-Based Payment Systems and Proposes Next Steps

A new policy statement aimed at clinicians treating patients with cardiovascular disease has provided a snapshot of value-based payment programs and laid out a vision for what they should look like as the US healthcare system increasingly shifts away from fee-for-service models..

For certain types of situations, getting paid for each discrete encounter, intervention, or procedure makes sense, “but for preventive care and chronic care, we’re really starting to understand that we need to move toward thinking about paying for care quite differently,” Karen Joynt Maddox, MD (Washington University School of Medicine in St. Louis, MO), vice chair of the American Heart Association (AHA) writing group and senior author of the paper, told TCTMD.

That’s where value-based payment models come in, and these can include programs ranging from those that provide minor financial incentives or disincentives depending on the quality of care delivered to broader population-based plans.

The latter “really tries to disrupt that kind of one-for-one payment model and instead moves toward trying to pay clinicians for managing the health of a population,” Joynt Maddox said. “We think that that would allow people to be more innovative and probably deliver care that’s more patient-centered. . . . It's really moving toward thinking about how we can manage patients and meet them where they are, and the current fee-for-service system just doesn't incent that at all.”

Over time, there has been a move toward value-based payment models, “but it really is a journey and it’s been sort of a slow and not-steady one,” Joynt Maddox said.

Published online Monday in Circulation, the policy statement, with Alexander Sandhu, MD (Stanford University, CA), as lead author and vice chair and Paul Heidenreich, MD (Stanford University and the VA Palo Alto Health Care System, CA), as chair, comes at a time when “there's broad recognition that we need to keep moving towards value-based and population payment models,” Joynt Maddox said. “We felt like it was the time to take stock, if you will, and look at what had been done and maybe where we should be moving we as collectively take that next step.”

Key Principles

The document is broken into several main sections, supported by examples from existing value-based payment programs:

• Key features of value-based payment systems and best practices, touching on patient populations, measurement of quality and cost, and risk adjustment
• The integral place in such models for considerations of the impact on health equity
• How to adjust payments when balancing costs and the quality of care
• How to implement and evaluate value-based payment programs

The authors also highlight four themes when discussing how value-based payment models can be successful in the future, discussing how they need to weigh quality and cost, consider equity as a vital component of quality, provide flexible options for funding team-based care and interventions that provide the most benefit to patients, and include clinicians as critical partners to both improve the quality of care delivered and reduce burdens.

It's really moving toward thinking about how we can manage patients and meet them where they are, and the current fee-for-service system just doesn't incent that at all. Karen Joynt Maddox

Greater adoption of value-based payment “really does involve moving more toward population health, really recognizing the centrality of equity to all of these pursuits,” Joynt Maddox said. “If we can't make care more equitable, then we're not making it higher quality.”

It also involves “moving towards recognizing that care, even for patients with cardiovascular disease, is really holistic and requires us to think about social needs to address the complexity that patients bring and really meet people where they are,” she added. “And so to the degree that payment models can be simplified and streamlined to push us in that population health direction, we think that's probably the best way for us to get the outcomes that our patients want.”

As a whole, clinicians can do a better job managing conditions like hypertension, diabetes, and heart failure, and moving away from fee-for-service models toward value-based payment could make a positive impact, Joynt Maddox indicated. “These payment models, I think, have a particular role in that outpatient space to try to free up clinicians to innovate and to be those managers and caregivers as opposed to just reacting when someone comes into your office every 15 minutes,” she explained. “It really is trying to use the payment to shift us to serve a more-proactive, population-management strategy that really fundamentally centers around quality, equity, measurement, those sorts of things.”

Reducing Burdens on Clinicians

A successful shift toward value-based payment models depends on not increasing burdens on clinicians, Joynt Maddox stressed. “What we don't want is to say that value-based payment should just make it all more complicated. I think what we're actually seeing in the milieu of value-based payment, but also trying to advocate for as specialists who manage patients both in chronic and acute settings, is really moving toward a lower-burden, more patient-centered, but also more clinician-friendly way of doing things.”

As it is now within fee-for-service systems, clinicians often are being asked to do more and more without additional payment, which “doesn’t really seem to benefit clinicians or patients,” Joynt Maddox said. “We’re hoping if done right, the [value-based] payment models could reduce burnout, could reduce burden, could lead toward people being able to get back to some of that more [patient-centered care] as opposed to just sort of the constant push for volume, volume, volume.”

If programs can be designed to not increase burdens on clinicians, or reduce them, there might still be some pushback from those who are set in their ways, she acknowledged. “I think the hardest part is just that it’s change, and change is hard.”

In that regard, this new policy statement from the AHA may get clinicians who care for patients with cardiovascular disease—which can include cardiologists and other physicians, nurses, physician assistants, social workers, care coordinators, and others—thinking about how to break away from the status quo. “How can we be part of the conversation to say we can move payment models to a place that makes it better for patients and clinicians if we really start moving toward population health?” Joynt Maddox said.

The paper notes that the AHA has been focused on promoting cardiovascular health as the larger health system moves toward value-based payment systems, teaming up in 2021 with the Duke-Margolis Center for Health Policy to provide recommendations to the Center for Medicare and Medicaid Innovation on how these types of programs can improve cardiovascular care. Those recommendations align with the principles discussed in the current policy statement.

“The principles delineated in this document will help to bridge the gap between the current state of value-based payment and its potential,” the authors state.