April 20, 2021

Volume XI, Number 110

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Value-Based Care in 2021: 5 Emerging Trends in Value-Based Care

The pace and pressure to embrace value-based care are picking up. The COVID-19 pandemic exposed the risks and limitations of reliance on fee-for-service reimbursement and, combined with the groundbreaking changes in health care delivery models and regulatory flexibility, indicate a renewed focus on value-based care.  This article outlines five of the top trends to watch for in value-based care for 2021.

1. Leaning In to Value-Based Care

One of the lessons from 2020 is that reliance on fee-for-service can leave providers vulnerable to volatility and changes in demand.  As utilization plummeted during the COVID-19 pandemic, providers who had invested heavily in value-based care have been better able to weather the pandemic and the economic downturn by having a consistent source of revenue despite low utilization.[1]  The rapid changes in health care driven by the pandemic only further emphasized the need for providers to lean into value-based care. Beyond the allure of steady revenue streams, new regulatory flexibilities and care delivery innovation creates an opportunity for providers to realize a more rapid rate of return on their investment in value-based care by increasing the portion of their business with value-based care reimbursement.

2. Continued Innovation and Disruption

While value-based care has always been an area ripe for innovation, 2021 presents a unique set of circumstances that point to a surge of innovation and disruption in both payment and care delivery models. Value-based care had been a priority for the Centers for Medicare and Medicaid Services (“CMS”) under the Trump administration,[2] but there is no reason to expect a change of course away from value-based care.[3] In fact, the Biden administration’s health care goals will likely require an increased emphasis on cost savings, which may result in an even greater push towards value-based care.[4]  Some news outlets are reporting that Elizabeth Fowler is a front-runner to lead the Center for Medicare and Medicaid Innovation,[5] further signaling that CMS’s momentum on value-based care will continue.[6] Commercial payors also continue to push towards innovative payment and care models as COVID-19 has highlighted the inequities in the healthcare delivery system and challenges for providers.

3. Capitalizing on COVID-19 Infrastructure

 The COVID-19 pandemic prompted transformational changes to the health care system that portend continued opportunities to manage patient care and provide quality care in lower cost settings. As a result of the pandemic, both the federal and state governments threw open the doors to allow providers to furnish services via telemedicine and other digital health modalities during the COVID-19 public health emergency.[7] Many of the telehealth waivers have been made permanent.[8] Providers who have embraced digital health as a way to weather the pandemic will also have the opportunity to capitalize on this investment as a way to manage patient care and see a return on investment for services that are typically not reimbursable under fee-for-service arrangements.[9]  CMS also created the Hospital Without Walls[10] and Acute Hospital Care at Home[11] programs to increase hospital capacity during the pandemic. Commercial payors have been eager to seize on these opportunities to promote lower-cost services.[12]  Providers who have invested in these types of programs similarly provide an opportunity to provide quality care in lower cost environments, which will benefit providers who are fully engaged in value-based care.

4. New Opportunities for Provider Alignment

Recent changes to federal law aim to lower barriers to value-based care. In particular, CMS and the Office of Inspector General (“OIG”) created new flexibility under the Stark law and Anti-kickback Statute for value-based arrangements to allow providers to enter into value-based care arrangements that previously may have been prohibited.[13]  While the new exceptions and safe harbors still require that arrangements be carefully crafted, they provide new opportunities to align with providers and to incentivize activities that promote value-based goals that were previously unavailable.  Additionally, the sweeping interoperability and information blocking rules aim to ensure that patients and providers are able to access health information, further reducing structural barriers to value-based care.

5. Emphasis on Social Determinants of Health

Finally, players in the value-based care space—particularly in Medicaid managed care programs—are placing greater emphasis on addressing social determinants of health.[14] Providers and payors are beginning to recognize the crucial role that non-medical factors play in patient health.[15]  By solving for these issues—such as transportation, food, housing, language services, etc.—providers and payors are able to realize significant benefits in improving patient health and outcomes while keeping medical costs relatively low. The focus on social determinants of health is an emerging trend in value-based care that is likely to grow as players seek creative ways to manage patient care through value-based arrangements.

As providers and payors emerge from the upheaval of the pandemic and the resulting revolutionary changes in health care, we can expect renewed interest in value-based care. Opportunities abound to capitalize on the changes wrought by the pandemic, as well as emerging prospects, by fully investing in value-based care.



[1] See, e.g. Jacqueline LaPointe, How COVID-19               Imperiled Physician Practices and How to Save Them, RevCycle Intelligence (May 6, 2020), ; How Value-Based Care Supports Doctors During the Pandemic, BlueCross BlueShield of Illinois (Sept. 9, 2020).

[2] See, e.g. Press Release, CMS, Fact Sheet: Value-based Care State Medicaid Directors Letter (Sept. 15, 2020), ; Press Release, CMS, CMS Announces Strong Participation in Value-Based Medicare Advantage Model for CY 2020 and New Opportunities for 2021 (Dec. 19, 2019), Press Release, CMS, Direct Contracting: Professional and Global (Nov. 25, 2019), .

[3] Keith Loria, What Will CMS Do Under the Biden Administration?, Managed Healthcare Executive, (last visited Feb. 10, 2021).

[4] See, e.g. Health Care, Biden Harris Campaign.

[5] Shira Stein, Obamacare Architect Is Top Pick to Lead Value-Based Care Office, BloombergLaw: Health Law & Business News (Feb. 10, 2021),

[6] See, e.g. Courtney Taylor, COVID-19 May Move the Needle on Value-Based Payment, USC Shafer (Sept. 24, 2020), .

[7] See, e.g., Telehealth, Polsinelli, (last visited Feb. 10, 2021); General Provider Telehealth and Telemedicine Toolkit, CMS, (last visited Feb. 10, 2021).

[8] See, e.g. Press Release, CMS, Trump Administration Finalizes Permanent Expansion of Medicare Telehealth Services and Improved Payment for Time Doctors Spend with Patients (Dec. 1, 2020),

[9] See LaPointe, supra n.1.

[10] Pres Release, CMS, Fact Sheet – Additional Background: Sweeping Regulatory Changes to Help U.S. Healthcare System Address COVID-19 Patient Surge (Mar. 30, 2020).

[11] https://www.cms.gov/newsroom/press-releases/cms-announces-comprehensive-strategy-enhance-hospital-capacity-amid-covid-19-surge; https://www.cms.gov/files/document/covid-acute-hospital-care-home-faqs.pdf

[12] See, e.g. Acute Hospital at Home Program, Frequently Asked Questions, (last visited Feb. 10, 2021); Press Release, Humana, DispatchHealth and Humana Team Up to Provide Hospital-Level Care in the Home (Feb. 1, 2021).

[13] Lori Oliver, Neal Shah, Jeanna Gunville, Kathleen Sutton, A New Framework: CMS and OIG Modernize the Stark Law and Anti-Kickback Statute, Polsinelli (Dec. 8, 2020).

[14] Addressing Social Determinants of Health & Equity Through Health-Related Services, Oregon Health Authority (Mar. 2020), ; Social Determinants of Health Dashboard, Wa. State Dep’t Health, (last visited Feb. 10, 2021); Marrying Value-Based Payment and the Social Determinants of Health through Medicaid ACOs: Implications for Policy and Practice, Milbank Memorial Fund (May 22, 2020), .

[15] Jacqueline LaPointe, Social Determinants of Health Key to Value-Based Purchasing Success, RevCycle Intelligence (Jan. 9, 2019).

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© Polsinelli PC, Polsinelli LLP in CaliforniaNational Law Review, Volume XI, Number 55
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Jeanna Palmer Gunville Health Care Attorney Polsinelli Chicago, IL
Shareholder

Jeanna Palmer Gunville’s practice focuses on corporate health care transactional work and regulatory matters. Her breadth of experience and in-depth understanding of the health care industry enable her to provide practical assistance to achieve her clients’ legal, business and operational objectives.

Jeanna counsels hospitals, health systems, academic medical centers, surgery centers, post-acute care providers and provider organizations on matters including:

  • Mergers, acquisitions and other change of control transactions
  • Strategic alliances,...
312.873.2950
Lori Oliver Health Care Lawyer Polsinelli Law Firm
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Lori Oliver’s practice focuses on a wide array of health care regulatory, transactional and operational matters. Her deep bench of experience and in-depth understanding of the health care industry enables Lori to offer practical solutions and strategic advice to clients. As a former health care executive, she has significant health care operational experience to draw upon. She has experience in health care alignments and relationship strategies, clinically integrated networks, health care operations and complex compliance matters, including fraud and abuse, Stark, HIPAA and state privacy...

206.393.5440
Kathleen Snow Sutton Healthcare Attorney Polsinelli
Associate

Kathleen Sutton’s practice focuses on an array of health care regulatory and business matters. She has experience representing academic medical centers, hospitals, ambulatory surgery centers, senior living communities, medical groups, and other health care providers, advising on transactional and regulatory matters, including:

  • Strategic planning to achieve business goals while navigating the complex interplay of federal and state laws that affect providers.
  • Developing and reviewing business arrangements and...
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