Charting the course: Our approach to transitioning to value-based care.

While a patient’s primary care physician (PCP) has the most holistic view of their clinical needs, they’re not always able to be present at key care interactions. PCPs must rely on strong collaborative workflows with the entire patient care team to achieve positive outcomes derived from value-based care. But so often, those pathways remain undeveloped.

Scott Mancuso, MD, chief medical officer for Honest Medical Group, has observed this dynamic in many care settings, from an integrated delivery system to an in-home care provider. While the clinicians and ancillary teams provided exceptional patient care in each individual patient interaction, he found the same limitation. “We didn’t intersect enough with the patient’s PCP,” says Mancuso. “Without a strong connection to the primary care physician, a patient’s overall care is still fragmented.”

For provider practices transitioning to value-based care, care fragmentation restricts their success. Mancuso saw an opportunity to solve this problem when he joined Honest. “I wanted to bring the best from both worlds: strategic and integrated clinical delivery services in facilities, patients’ homes, and the clinic to manage patients with complex conditions. All of this is done under the purview of the primary care physician, who has the most holistic view of patient goals and preferences.”

Mancuso sees a clear path to help PCPs excel in value-based care with novel Medicare programs. “Our clinical model is a partnership with PCPs to reduce burnout and enhance longevity,” says Mancuso. “Provider satisfaction is our number one goal, and the patient is the number one stakeholder.”

The path to value-based care

Because Honest partners with physicians, a thoughtful approach that minimizes physician abrasion while demonstrating early results for patients is paramount. “We start with minimal disruption to the PCP clinic workflow and create the financial infrastructure for PCPs to be successful,” says Mancuso.

For example, Honest often finds that patients who could benefit from home care drive 35% to 40% of hospitalizations. In turn, these stays increase the volume of post-hospitalization visits and calls to the PCP. By implementing collaborative programs like Care at Home, Honest can support PCPs and help prevent hospitalizations in this group by 15% to 20% when providing care directly in the patient’s homes and with longitudinal support from a robust interdisciplinary care team.

To give physicians the foundation to be successful in value-based care, Honest leads with a clinical model designed to:

1. Understand patient risk through data and evidence-based insights;
2. Align contracts and incentives while reducing care variability; and
3. Support physicians with the operational demands of value-based care.

Understand patient risk through data

“The first step is to start with data,” says Mancuso. “We aggregate and reconcile data for PCPs in a way that helps them more proactively understand the complex health needs of their patients and their preventable cost drivers. Our goal is to move primary care from a reactionary inbound model of delivery of care to an outbound practice focused on preventing chronic conditions and their secondary complications.” Equally important is ensuring their documentation achieves appropriate accuracy, which forms the basis for meaningful insights and care interventions.

Reduce contract variability and align incentives

PCPs juggle multiple payer types with distinct benefit packages. Each payer requires providers to adjust their care decisions based on fluctuating guidelines. Honest first helps practices reduce contract variability so physicians can reduce care variability.

“We try to move all those payers to one contract,” says Mancuso, “so physicians have one way of caring for their entire patient panel.”

When transitioning to value-based care, a PCP must also shift their mindset from reactive to proactive, from encounter-based to year-round care. Instead of addressing a patient’s health needs during a 15-minute visit, they must reorient and proactively connect with patients to manage their needs before they affect their health.

Because value-based care holds physicians accountable for these broader scopes of services, Honest works to align payment models to incentivize that scope. “For example, we’ll move the fee-for-service Medicare plans into one cost-of-care payment model for providers, such as ACO REACH. We work with payers on behalf of our physician partners to shift Medicare Advantage plans to a global risk contract — a total cost of care model.”

Support physician-led care with a team of services

At Honest, we champion the notion that PCPs are best positioned to help their patients — they just need more support.

“As an internist, I wasn’t taught how to address food insecurity or loss of residence,” says Mancuso. “But in value-based care, you need a solution if your patient struggles with access to healthy foods or is at risk of losing stable housing. You need to help them get access to meal delivery or a roof over their head, find financial aid so they can afford medications, and connect them with community resources to avoid negative health outcomes.”

Honest offers these types of clinical capabilities and wrap-around services to meet patients’ social, behavioral, and functional needs while meeting the operational demands of proactive care. That team includes a variety of providers with different roles:

• Nurse practitioners conduct home visits.
• Social workers build relationships with community resources like food banks and homeless shelters.
• Pharmacists perform medication management for conditions like diabetes and heart failure while identifying lower-cost alternatives for patients.
• Nurse care managers help bridge the gap between the PCP and specialists, perform patient education, and arrange follow-up care.

The Honest care team huddles daily and holds structured weekly meetings where everyone on the team has an equal voice to collaboratively create robust care plans for the most complex patients. “That level of multidisciplinary care planning doesn’t exist today,” says Mancuso. “It sounds simple, but it’s not; it takes a lot of work to get there.”

Comprehensive, individualized care plans lead to better patient outcomes. Patients with chronic conditions experience secondary complications less often, and they utilize emergency rooms less frequently, live longer, and pay less for care. Physician savings create stability so they can invest in other services to improve care delivery, like behavioral health support or remote patient monitoring.

Forging a unique path for physicians to embrace change

Other value-based care partners focus solely on patient data at the expense of driving lasting operational change. “If you don’t have the capabilities in place, you just have more insight into your problem,” says Mancuso. “And it often ends there.”

In contrast, Honest uses data to help physician partners set up and deploy the wrap-around services they need to support their patients. This two-pronged approach optimizes revenue and reduces medical expenses.

Honest looks ahead to adapt its clinical model continuously. In monthly medical operating committee meetings, physician partners share their challenges. Mancuso also hosts a national clinical leadership council where physicians and health plan partners gather with nationally recognized thought leaders. Together, they aim to solve problems in value-based care and get ahead of the curve with new solutions, such as health equity initiatives and food pharmacies. “We’ve taken lessons from this committee to rethink how we address these challenges for our physician partners.”

Physician partners of Honest have seen the benefits of this proactive approach early on:

• Patients in Care in Motion, a transitions of care program, have a 17% reduced readmission rate.
• Patients in the Care at Home program (primary care delivered in the home) have a 20% reduced hospitalization rate.
• Patients in the Care at Home program show a 40% decrease in total cost of care.

“Early data from these programs have been exceptional,” says Mancuso. “It shows that, when delivering these programs in concert with PCPs, we can reach success in value-based care much more quickly.”

Learn how Honest can support you and your team in the transition to value-based care.