McKesson's David Nace, MD, on value-based care
David Nace, MD, is vice president and medical director at McKesson Health Solutions, McKesson Technology Solutions (MTS). Prior to McKesson, Nace served as a senior vice president and a chief medical officer with Aetna.
Q: What kind of market alignment is necessary to get payers moving in the same direction to achieve value-based care?
A: To get payers moving in the same direction, payers need alignment within the medical service area in terms of a new way to pay for care. The question is whether they should align around shared savings, bonuses for quality or a blended scheme. While they cannot agree on price, they should be able to agree around some measure of quality and how that’s tied to reimbursement.
What we saw in California eight years ago with Integrated Healthcare Association (IHA) provides an example of what can work. IHA found a way to get everyone to the table and agree on a set of metrics tied to quality. They then worked with a third-party organization to pool dollars and pay bonuses to providers within the context of the same set of metrics.
It’s easy to align around quality and/or payment models and more complicated around costs, but what’s most important is to collaborate and be willing to come to the table.
Q: How do you make value-based care a priority for providers in the wake of all the other competing priorities and constantly shifting regulatory requirements?
A: You need a catalyst and an incentive. We all understand that costs are growing at an unsustainable rate. To remain relevant and competitive, payers, hospitals, health systems and clinicians all must respond now and integrate value-based models into their existing systems. But without the appropriate investments in contemporary healthcare IT to enable new and mixed reimbursement models, the systems will be pushed beyond the breaking point. Technology can automate much of the complexity in value-based reimbursement, and it can also serve as the catalyst to clinician engagement.
Of course, the incentive comes in the way of the new reimbursement model. Commercial payers have typically followed Medicare’s lead. Until now, payment policy has been controlled by Congress. Now with the Affordable Care Act, Medicare payment policy and innovation comes more directly under the control of the Department of Health & Human Services, allowing more flexibility in being able to try (and if successful expand the use of) new incentive programs that support the transition to value-based care.
We are seeing signs that the catalyst and incentive duo is working through studies like the one by ORC International, which we commissioned at McKesson. The study indicates that a third of provider reimbursement is already based on some mix of a value-based model. The same study showed that a full two-thirds of the market will be using value-based approaches by 2020.
Q: What cultural changes can help with physician buy-in?
A: Providers will tell you they’re comfortable with the idea of being measured, evaluated and reimbursed based on performance, but I’m not sure about that. By our very nature, doctors are competitive and are very wary about being told that what we’re doing is being measured or judged, especially in ways we don’t fully understand or do not feel are under our control. There’s also an enormous cultural shift as we move away from the comfort of payment for individual services rendered on a patient-by-patient basis.
Both payers and providers will tell you that the single most significant obstacle to transitioning to value-based care is clinician buy-in and engagement. In my opinion, you need three things to reduce this obstacle. You need a physician leader, you need collaboration, and you need a process and information that doctors and other providers trust and understand.
A physician leader, such as a medical director, can champion the technology by helping other doctors understand what’s being measured and why it’s being measured.
We also need to create more collaboration so doctors get involved in the process instead of simply being told they’ll be measured by X. At McKesson, we make the technology available and urge doctors to be involved in the process of understanding and being involved in capturing the necessary data.
When looking at the data, they need to understand what the measurements are, why the metrics were chosen, what it reveals and how it will impact them as well as how it impacts the patient and payer. That’s when we’ll start to see doctors have an “aha” moment.
And that’s the process I’ve seen have success around the country: talk about the program, be transparent about measurement, and give providers a way to show physicians they’re being measured fairly.