In the podcast episode, Dr. Kosinski speaks with Krishna Ramachandran, Senior VP for Health Transformation and Provider Adoption at Blue Shield of California, discussing the challenges of implementing value-based care (VBC) across different states, especially contrasting California’s capitation-heavy system with Illinois’ more fee-for-service model. Ramachandran notes California’s collaborative, multi-payer approach driven by various stakeholders, including employers, regulators, and nonprofit organizations. This cooperation supports a healthcare system focused on affordability and value, while Illinois has relied more on initiatives like Blue Cross’s capitation.

They explore Blue Shield’s evolving VBC strategy and the role of Accountable Care Organizations (ACOs), emphasizing that while CMS interactions with ACOs should avoid being overly prescriptive, creating a flexible framework for quality measurement and cost reduction remains vital. Ramachandran highlights Blue Cross Blue Shield of Illinois’s efforts to support providers with necessary tools for data exchange, surfacing insights, and analytics.

Ramachandran explains Blue Shield’s “rebel with a cause” mission to build a healthcare system worthy of friends and family, describing a strategy focused on four pillars: digitizing healthcare data, tying payments to value, making prescription drugs more affordable, and promoting health equity. Blue Shield partners with community-focused providers and invests in digital and virtual platforms for various chronic health conditions, which have significantly reduced costs and improved care quality among primary care providers in their VBC arrangements.

In the final segment, they discuss involving specialists in VBC models, like SonarMD. Dr. Kosinski notes that gastroenterologists still derive much of their income from elective procedures like colonoscopies, a challenge when shifting to VBC. Ramachandran suggests blending total cost of care models with episode-specific approaches, leveraging insights from specialty societies and associations. Both agree that the journey to a fully integrated VBC system requires a holistic rethinking of payment structures and strong partnerships with providers and specialty groups. Dr. Kosinski concludes by expressing excitement for future collaborations with Ramachandran and Blue Shield to drive innovation in VBC through SonarMD.

Key Takeaways:

1. Innovative Provider Partnerships: Partnering with providers helps bring impactful tools and incentives that improve healthcare quality and affordability.
2. Payer-Driven Transformation: Aligning financial incentives across healthcare systems can move services to cost-effective settings while maintaining quality.
3. Holistic Care Models: A varied portfolio of models, from total cost of care to episodic care, is essential for delivering comprehensive, value-based care.

Quote:

“To truly innovate in ACOs without strict mandates, we need to focus on how we can engage providers in creating value-based care models that not only improve quality but also bend the cost curve. It’s essential to measure what truly matters and support providers with the resources and data they need to succeed.”