Despite decades of effort at the regulatory level to increase access to high-quality and affordable healthcare for all Americans, millions remain stranded in medically underserved communities across the country. As chief medical officer of VillageMD, I know firsthand how federal policy shapes both the physician and patient healthcare experience. Incentives matter: They heavily influence where and how care is delivered.
The right incentives can create a long-term, trusted relationship between physicians and patients that encourages improved healthcare outcomes. They can nurture an environment in rural and urban areas alike where the kind of care you would want for a family member prevails.
The wrong incentives can lead our healthcare system further down a financially unsustainable path and perpetuate the deep-seated inequities that leave many Americans with the same healthcare disadvantages as generations before. Our traditional healthcare model drives primary care providers to prioritize volume of care without recognizing the value that consistency, coordination and personal trust bring to patients.
The current structure has undesirable consequences. Disadvantaged populations end up “riskier” to care for, and as a result they consume more healthcare resources. Our healthcare system doesn’t incentivize providers to serve in some areas. That leads to communities with limited access to high-quality primary care, leaving more people prone to long-term health issues.
Value-based care focuses on outcomes. It promotes prevention, wellness and the management of chronic conditions. To advance health equity, value-based care programs administered by the Centers for Medicare and Medicaid Services compensate providers for achieving better results. By allowing physicians to focus on helping patients avoid unnecessary illness and disease progression, value-based care empowers more of them to practice in underresourced communities and choose a sustainable alternative to reactive and costly fee-for-service healthcare.
The Center for Medicare and Medicaid Innovation this year introduced the Accountable Care Organization Realizing Equity, Access and Community Health program, a promising model worthy of deeper refinement. It promotes value-based care over fee-for-service and aims to spread those benefits to medically underserved areas by addressing the shortage of primary care providers where they are needed most.
Providing excellent primary care in these communities is not for the faint of heart. It requires organization-wide commitment and physicians backed by comprehensive care teams. We want providers to be able to spend more time with patients and deliver care on a deeper level in all communities. Leaders must help federal policymakers understand that while introducing ACO REACH is a good start, two elements of the program—both related to incentives to care for riskier populations—must be updated to ensure the program’s long-term success.
The first element limiting primary care physicians’ ability to thrive in underserved areas is the Retrospective Trend Adjustment (RTA). It is how CMS incorporates patient risk into the amount providers are reimbursed for care. Adjusting reimbursement for care after it is delivered creates uncertainty for providers, limiting the long-term infrastructure and staffing investments necessary to meet the needs of previously underserved populations.
Another challenge physicians face is the risk adjustment cap. Underserved populations are historically underdiagnosed and don’t receive proper care. Coding for their medical conditions is often inadequate at the beginning of the primary care relationship. An artificial cap limits the amount of reimbursement providers receive for accurately documented medical conditions and thus hinders providers’ ability to invest in their communities. In the long run, it will reduce the availability of high-quality, outcomes-oriented healthcare.
Mismatched incentives are forcing ACO REACH participants to rethink the viability of providing care in underserved communities. The good news is there are clear steps to strengthen this important health equity program. Policymakers should provide a risk corridor to limit reimbursement uncertainty associated with the RTA and implement new risk-adjustment standards to accurately capture the information of historically underserved and unattributed patients.
As healthcare leaders, we must not allow the decades-old challenge of expanding care for these underresourced communities to remain unresolved. Ensuring the long-term success of ACO REACH and programs like it requires us to continuously engage with policymakers regarding the challenges on the front lines of healthcare.