Introduction
Value-based payment (VBP) is designed to support collaborative partnerships between patients and physicians, improve the quality of care, and reduce health care spending. To achieve these aims, VBP for primary care must support the four key functions of primary care (i.e., first-contact access, comprehensiveness, coordination, and continuity), which are essential to meeting the goals of improved quality and reduced spending.1 The success of VBP is highly dependent on alignment across payers and unlikely to work if only a small subset of a practice's patient population is included. Increased investment in primary care across public and private payers using VBP models designed for primary care will contribute significantly to improving health, eliminating inequities, reducing the per capita cost of care over time, and improving the well-being of the care team.
To help facilitate the transition away from fee-for-service (FFS) payment and towards VBP arrangements that sustainably support the kind of robust primary care that is essential to a high-performing health care system, the American Academy of Family Physicians (AAFP) has established a set of guiding principles to describe the ideal design for key components of VBP models for primary care.1
This paper and others in the series aim to translate the guiding principles into actionable steps that key stakeholders can use to implement VBP models that sustainably support primary care. The AAFP will provide background information, industry context, and stakeholder recommendations, along with our expertise, to offer a broad understanding of the issues unique to primary care in VBP implementation.
This call-to-action brief focuses on the following principles:
Clinically relevant and actionable patient information should be readily available in a timely, accurate, secure, and efficient manner that does not place unnecessary administrative or financial burdens on primary care practices.
The sections below address reasons family physicians should become familiar with the current industry state of information sharing for primary care, its role in VBP programs, areas of success, areas that need improvement, and recommendations for stakeholders to drive greater implementation of these guiding principles.
Rationale for Action
Continuous, comprehensive, person-centered and value-based primary care cannot be delivered in a vacuum. It requires the following essential information to be shared securely across the continuum of care without significantly burdening patients, physicians, and/or other clinicians:
Comprehensive information on the patients for whom physicians are accountable. Delivering coordinated, high-quality patient care in VBP models requires that physicians receive timely notification of the patients for whom they are responsible and have easy access to complete longitudinal patient information, including care provided in other settings. For more information on best practices for attributing patients to physicians within VBP models, see the AAFP’s Value-Based Primary Care Establishing Accountability Call-to-Action Brief[MM1] .
Actionable cost and quality information regarding other sources of care. For primary care physicians to facilitate high-quality, cost-efficient referrals, complete information on the quality, safety, and cost of care (including out-of-pocket costs to patients) should be readily available to inform physicians about high-value medical decision-making.
Timely information on physician performance. Success within value-based agreements requires physicians to receive ongoing feedback detailing their performance against predetermined targets throughout the contract period.
Importantly, primary care physicians require access to this information—regarding patients, other sources of care, and VBP performance—at the right time, within optimized clinical workflows, and in an actionable format.
Unfortunately, for the reasons discussed below, basic requirements for sharing this information remain elusive despite the widespread growth and availability of digital technologies and many years of targeted policy interventions. Many attempts to support information sharing in primary care fail to provide the intended benefit of improved patient care and add unnecessary work to already overburdened family physicians, contributing to mounting dissatisfaction and burnout.2 According to a 2014 survey of 382 physicians across 47 states, 61% of respondents felt that mandated electronic health record (EHR) systems added unnecessary difficulty to their clinical workflow and operations.3 Recent studies confirm this sentiment has not improved, despite nearly a decade of widespread EHR adoption. EHR systems are frequently mentioned as physicians’ most prominent stressor, with nearly 75% of primary care physicians identifying the EHR as a source of burnout.4 A leading cause of these physician challenges is that EHRs have focused on automating the billing process, not care delivery. If unaddressed, the move to VBP may exacerbate current EHR limitations and contribute to the administrative burdens that diminish the well-being of physicians and other care team members.
Ensuring primary care physicians and their care teams are equipped with the information they need when they need it and in a format that can be readily incorporated into practice workflows will require the organized efforts of all stakeholders. Stakeholders include purchasers (e.g., employers and/or union trusts who purchase health care on behalf of their workforce); public and private payers (e.g., Medicare and commercial health insurance companies); policymakers (e.g., lawmakers and regulators); physicians; organizations that employ family and other primary care physicians; and data and health information technology (IT) vendors.
Considering the potential promise and shortcomings of VBP models for primary care, the AAFP recommends the following actions for various stakeholder entities to address the information gaps currently existing for primary care practices delivering value-based care.
Table 1. Actions to Focus on Information Sharing
The Current State
Family physicians and the health care industry have long used data to inform clinical decision-making and payment. Although there is widespread understanding of the importance of sharing these data and establishing systems for doing so, current efforts have yet to meet industry goals.
Efforts to create a functional health information exchange (HIE) infrastructure in the United States date back to 2004, when President Bush signed an executive order instructing the Secretary of Health and Human Services to appoint a National Health Information Technology Coordinator (National Coordinator) charged with building a “nationwide interoperable health information technology infrastructure.”6 Despite almost two decades of work, the vision of the executive order remains aspirational, though progress towards establishing this infrastructure has been made through the following goals7:
Building on the vision established by the 2004 executive order, the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009 provided more than $35 billion to physicians and other care delivery organizations to encourage the adoption of EHRs.8
As indicated in Figure 1, by 2021, nearly 4 in 5 office-based physicians (78%) and nearly all non-federal acute care hospitals (96%) used a certified EHR—marking substantial progress since 2011 when only 28% of hospitals and 34% of physicians had adopted an EHR.9
Figure 1. Trends in Hospital and Physician EHR Adoption
From Office of the National Coordinator for Health Information Technology. National trends in hospital and physician adoption of electronic health records. https://www.healthit.gov/data/quickstats/national-trends-hospital-and-physician-adoption-electronic-health-records.
Notwithstanding these improvements in EHR adoption rates and incremental improvements in the functionality of information-sharing technology in general, the vision for a well-functioning ecosystem for HIE—and the ability of physicians to have access to the right information, in the right place, at the right time—has not yet been achieved. While these technologies have been in the hands of physicians, and policies have mandated their use, meaningful improvements in physician access to essential information in a usable format have been slow. According to surveys by the Office of the National Coordinator, progress towards engagement in the four domains of interoperability—sending, receiving, searching/querying, and integrating external health information—remains slow, with only 16% of physicians reporting participation in all four domains in 2021.10 This is inadequate for primary care physicians, whose information needs are central to delivering optimal patient care and succeeding in VBP.
One advanced technology that holds tremendous promise is artificial intelligence (AI). Today we are seeing practices take advantage of AI to reduce administrative tasks. This allows more resources to be dedicated to patient care and more impactful work. We are also seeing AI that can help summarize patient data and surface gaps in care. This can lead to improved patient health and wellness and reduce the administrative burden placed on clinicians to make sense of increasingly voluminous amounts of data and information. For example, clinical "AI Assistant" technologies available today are like having a chief resident on your shoulder at all times, calling the clinician’s attention to information to be aware of while reducing time spent searching for missing information. The use of AI technology to assist physicians with coding to support accurate payment and risk-adjustment is also growing; unfortunately, these capabilities are not yet equitably in the hands of all primary care physicians. It is reasonable to expect AI to have a profound impact on data collection, risk assessment, patient risk management, and patient engagement in the near future. All of these opportunities can support and accelerate the adoption of value-based payment, drive high-quality primary care, and improve clinician well-being if the implementation challenges can be properly addressed. While AI shows great promise, the AAFP offers the Ethical Principles of Artificial Intelligence in Family Medicine to help guide the market’s growing appetite for AI-enabled capabilities to ensure its accurate and equitable implementation.
What Is Not Working
Issues with health information sharing can be broadly categorized into three areas. Many complications stem from the nature of the market and regulatory environment that dictates the financial incentives behind information-sharing efforts or lack thereof. Other challenges are due to the nature of the technology used for sharing health information. Additionally, some issues result from imperfect data and data-sharing practices.
Environment
Information sharing is often built around payment rather than care, which leaves payers and others little incentive to participate in data sharing. Payers can play a significant role in facilitating the flow of patient health information thanks to their visibility into an individual’s comprehensive care journey. However, few share these data with primary care physicians in an organized, accessible, and timely manner. Even when payers participate in information-exchange activities, they often prioritize receiving information to support their own operations over providing information that can inform physicians about the health of their patients in a timely manner. One study found that private payers are much more likely to receive data (56%) than to provide data (36%) in an HIE or interoperability framework.11
Health care is built on a massive, fragmented network of systems not well-designed to exchange information. The fragmented nature of the U.S. health care system is not well-equipped to sustain accurate and timely information exchange. Patients receive care across a variety of health care settings that lack an organized or efficient way of exchanging health information and the financial incentives to do so. Frequent health plan churn—with the accompanying changes in networks—can result in further information fragmentation as patients seek new sources of care to remain in-network after a plan transition.12 This is further complicated by the broad insurance networks of preferred provider organizations (PPOs)—the type of health plan through which nearly half of Americans with employer-sponsored insurance are covered—which require physicians to obtain essential information from an increasingly extensive network of care providers.13 Of course, these challenges are not limited to employer-sponsored plans. The typical primary care physician with Medicare patients must coordinate with 229 other physicians and 117 other practices.14 Many states are working with HIEs to ensure health care data can be shared openly across contributing organizations. However, the actual creation and sophistication of these HIEs have been inconsistent across states and local geographies, and not all care delivery organizations participate. Even when participation is high, data exchange between disparate HIEs can be challenging—especially in geographies bordering different states or operating under competing HIEs.
Technology
Health IT platforms are designed not to be interoperable. Despite recent regulations to prohibit information blocking, a market-driven strategy demonstrated by many EHR vendors is to limit interoperability to lock physicians into their ecosystem.15 EHR vendors know physician organizations and patients value longitudinal data records, so building walls between systems can protect market share. Furthermore, changing technology vendors is a majorly disruptive and expensive endeavor. Even HIEs specifically intended to allow for data sharing across organizations on different EHRs sometimes grapple with conflicting incentives to both share and retain data, especially in states such as New York or California, where multiple HIEs actively compete.
Designed fundamentally as billing systems, health IT tools are expensive and difficult for clinicians to use. Health IT tools are expensive, especially considering the added costs associated with implementation (e.g., training, lost productivity, etc.). In addition to an average upfront cost of $26,000-$33,000, physician practices spend between $685 and $1,200 per user per year on EHRs.16 Despite these costs, many EHRs are not user-friendly or efficient for clinical personnel since most are primarily built around billing, not patient care. Working within systems not designed to support and seamlessly integrate into clinical workflows leads to physician burnout.17
No health IT platform offers a holistic solution to care. Assuming responsibility for the holistic care needs of patient populations under VBP requires care delivery organizations to fundamentally reorient how they operate to proactively identify patients’ clinical and social needs, assess the effectiveness of interventions, coordinate care across settings, and more. Navigating this transition requires practices to invest in multiple tools, each operating with its own data environment and interoperability challenges. In addition to the EHR, physician practices will often pay separately for an enterprise data warehouse, analytics platform, care management solutions, and even separate tools for data visualizations. Remember, these disparate solutions to support population health management are in addition to other traditional solutions required to run a practice. The cost of implementing and maintaining these disparate solutions is a barrier for small, independent practices.
Data
Even if systems and processes for information sharing were improved, the data shared to support VBP success is still lacking. Claims data are inherently dated (lagging between 1-3 months on average) based on billing for services that have already happened, decreasing its usability for physicians when making informed decisions at the point of care or proactively identifying patients needing timely care management interventions. Furthermore, claims data can include inaccuracies attributable to human error and provide only a limited picture of a patient’s care. These issues can sow distrust in the data among physicians who need integrated administrative (claims) and clinical data to be confident enough to act on the information.
Obtaining data can be difficult, time-consuming and expensive. As mentioned, many payers don’t make their claims data readily available or don’t provide data in an actionable format for physician practices—even under VBP contracts. Additionally, some patients are reluctant to share certain types of information, including social determinants of health (SDoH), mental health, substance use disorder, race, and ethnicity data. Obtaining access to information regarding the cost and quality of services performed outside of a family physician’s office in a timely manner can also be a challenge, adding to difficulties in managing complex patients. Moreover, some forms of data are difficult to obtain simply because the industry lacks specific standards for defining, collecting, managing, and sharing these insights. For instance, a recent analysis of SDoH integration into EHRs reveals a lack of consensus on standards for capturing and representing SDoH data across the array of EHR systems currently in use.18
What Is Working
Although challenges remain in realizing the vision of a nationwide, interoperable health IT infrastructure, progress is being made in the ever-evolving information-sharing environment through advancing technology and improvements in data use.
Environment
Stakeholders continue to push for and implement interoperability standards, although the impact on physician access to information varies. Building on the efforts of the 2004 executive order and 2009 HITECH Act, national efforts continue to promote health information sharing through the 21st Century Cures Act passed in 2016. The Cures Act requires that patients have electronic access to all their electronic health information at no cost and implements penalties for intentional information blocking with limited exceptions.19 Furthermore, the national adoption of the Trusted Exchange Framework and Common Agreement (TEFCA) and Fast Health care Interoperability Resources (FHIR) seeks to improve health information transfer by establishing a universal floor for interoperability and standardizing how health information exchange is governed across the country.20,21 Still, the impact of these initiatives is yet to be determined, with many primary care physicians skeptical of these efforts due in part to the lackluster results of past reforms, which generally increased administrative burden and had an underwhelming impact on access to essential and usable data.3 While setting interoperability standards is necessary, policymakers should ensure that this work is followed by evaluating whether these efforts lead to intended improvements in information sharing that support more efficient delivery of care and better patient health outcomes.
Payers administering VBP programs are (generally) facilitating more information sharing relative to the start of the value movement, but additional consolidation of information reporting is needed. Realizing the critical role of timely information in improving patient care, some administrators of VBP programs are working to improve participant performance by implementing more robust data-sharing processes directly into model requirements. The Center for Medicare and Medicaid Innovation (CMMI) exemplified this trend with the Comprehensive Primary Care Plus (CPC+) model, introducing data-interoperability requirements and information-blocking standards and working to align these efforts across payers.22 Similar efforts continue with the Primary Care First (PCF) model, which also requires data exchange with other health systems and connection to a regional HIE but without the same level of multi-payer alignment experienced in CPC+.23 Similarly, in response to stakeholder feedback, Medicare Shared Savings Program participants now receive monthly and quarterly reports unavailable in earlier program years. While these improvements are laudable, most payers are not yet supplying VBP participants with the information they need to be successful. Additionally, even if one payer optimizes information sharing to support value-based primary care, this represents only a portion of a practice’s patient panel, as primary care practices frequently contract with ten or more payers.24
Technology
The VBP-oriented health IT tools market is maturing, and the growing number of practices participating in VBP are driving improvements in the interoperability landscape. Compared with the start of the value movement, practices and other care delivery organizations can choose from a greater number of health IT solutions. The maturation of the vendor industry has seen the addition of new business models—some of which are willing to take on financial risk—including a market for technology-based VBP “enablers” who partner with physician organizations to improve care, engaging in shared savings arrangements where the enabler only gets paid when the physician practice is successful. The improvements in health IT tools have been driven, in part, by the increasing number of practices participating in VBP. These practices require health IT solutions that enable success under VBP arrangements, including access to timely data, advanced analytics, and care-oriented (rather than payment-oriented) tools. Studies show that advanced practice models, like accountable care organizations, clinically integrated networks, and integrated delivery networks, are more likely to use HIEs and share patient information (such as patient care summaries and lab results) than physicians in traditional care delivery models.25
Physician practices and care delivery organizations are becoming smarter shoppers. As the VBP health IT solutions market has matured, so have physician practices and other care delivery organizations. They have improved their ability to recognize which data are useful for improving patient outcomes, where and how to locate and access the information, and how to determine which specific product components/functionalities are necessary when evaluating a value-based health IT tool.
Data
Health care organizations and stakeholders are beginning to understand and use nontraditional data sources that help improve patient outcomes. New data sources that help organizations engaged in VBP arrangements to manage patient outcomes and control costs are increasingly available and utilized in health care. Examples include data from remote patient monitoring devices, wearables, and mobile health apps that can provide frequent data points to help generate a more comprehensive view of a patient’s health. Many health care stakeholders now collect, analyze, and act upon SDoH data—with a growing number of public and private social-focused solutions, including community care hubs, designed to facilitate connections to community resources that can address unmet social needs. Recognizing the impact SDoH factors have on health, initiatives such as the Gravity Project are working to develop standards for collecting this important data. Building on and driving this momentum, the Centers for Medicare and Medicaid Services (CMS) is advocating for the increased collection of SDoH data to identify major gaps in data quality, accuracy, equity, and completeness, including the provision of health equity data collection in its newest VBP models—Accountable Care Organization Realizing Equity, Access, and Community Health and Enhancing Oncology Model ACO REACH and EOM.26
Call to Action
The AAFP calls on stakeholders to make health care information regarding patients, sources of care, and VBP performance readily available to primary care physicians at the right time, within optimized workflows, and in an actionable format. Likewise, stakeholders should work to improve patient access to information regarding the cost and quality of health care services while easing the burden of data collection on patients by designing tools and processes with their needs in mind.
The AAFP calls on stakeholders to support the creation and implementation of minimum health information-sharing requirements to more adequately address baseline needs of primary care, as well as the support of health IT platforms to efficiently implement those requirements. Even without shared agreement on minimum information-sharing requirements, stakeholders should incorporate their own minimum requirements for the type, frequency, and form of information that will be shared in VBP agreements.
Finally, the AAFP calls on stakeholders to design information-sharing platforms and procedures that limit the cost and disruption of implementing and maintaining health IT tools and services, improving cost transparency, and ensuring information systems can support the unique needs of small, rural, and independent physician practices.
References
(April 2024 BOD)