How Pearl Health Is Helping Primary Care Lead The Value-Based Care Charge

Despite spending close to twice as much per person on healthcare, the U.S. achieves worse health outcomes.

With U.S. healthcare costs now accounting for close to 20% of the country’s GDP, is the way to slay healthcare’s cost leviathan by helping primary care physicians participate more easily and effectively in value-based care programs?

Healthcare technology company Pearl Health is betting so.

Launched in November 2020, Pearl Health’s technology platform helps independent physician practices participate in value-based care models. Pearl has seen 10x year-over-year growth, expanding from 10 to 29 states, which company CEO Michael Kopko attributes to the industry’s increasing recognition of how enablement technology can be the missing piece in helping providers perform successfully in value-based arrangements.

“We recognize that providers have been overburdened with administrivia and buffeted by the demands of the Covid-19 pandemic,” says Kopko below, adding that previous iterations of value-based care models did not go far enough to align provider incentives to outcomes.

“Primary care providers are the quarterbacks of our healthcare system, and therefore the logical initial partners in our efforts to achieve change,” explains Gabriel Drapos, Chief Operating Officer at Pearl. Organizations like Pearl Health both help providers evaluate their options and enable their success upon enrollment.

In this Q&A, Kopko and Drapos discuss the shifting value-based care framework and technology landscape, including what physicians should consider when evaluating the different avenues available to them, from the ACO REACH program to the more recently announced Making Care Primary program. Kopko and Drapos also discuss how Pearl’s platform is giving providers the tools they need to create patient-centric alignment and make value-based care participation as efficient as possible.

Q: You just published a robust response article in Health Affairs – what prompted you to respond, and what message are you hoping to get across?

Gabriel: Our Health Affairs article was a response to a recent Health Affairs publication, Explaining Corporate America’s Aggressive Investment In Primary Care. While we agree that the ongoing consolidation of healthcare companies may be cause for concern, attributing this trend to value-based care is misguided. Ultimately, we advance two claims:

1. The authors overlooked critically important trends in value-based care over the last decade – namely, the Medicare Shared Savings Program and the slew of test models released by the CMS Innovation Center (CMMI); and
2. That, through these initiatives, regulators have generated a diverse, vibrant landscape of new companies that are both challenging incumbents and developing capabilities essential to controlling healthcare costs.

Q: After more than a decade of value-based care efforts, the U.S. still pays about twice as much for healthcare than any other country, despite underperforming in quality and outcomes. Accountable care organizations (ACOs), once heralded as the model for VBC enablement, historically haven’t delivered the cost savings or improved health outcomes as intended. Why have ACOs not delivered consistent savings?

Michael: Previous iterations of value-based care models were important steps forward, but ultimately they did not go far enough to align providers’s incentives to outcomes. A few specific thoughts:

• Marginal quality-based upside on fee-for-service approaches has not generated the appropriate incentives: providers do a lot of work each year, and then, eighteen months later, they may get savings – which may or may not be diluted by other ACO participants. At Pearl, we give practices a path to individualized risk pools – obviating dilution – and quarterly payments aligned to leading indicators of value to engender more substantive alignment.
• Past models have kept one foot in the fee-for-service door, while trying to move providers away from volume-oriented revenue structures. Stable cash flow, like REACH affords, is needed to enable a meaningful rotation to value.
• ACOs with greater provider participation in governance and oversight tend to perform better. REACH mandates 75% participating provider representation on ACO boards.
• There has been too much focus on process-oriented quality measures that show little actual relationship to outcomes, while inundating providers with burdensome reporting requirements. ACO REACH has removed these measures from program requirements, focusing instead on outcomes-oriented quality metrics and risk-adjusted spend management.

Q: Providers now have options when it comes to choosing ACO program participation: the Medicare Shared Savings Program (MSSP), and the recently-implemented ACO Realizing Equity, Access, and Community Health (REACH) program?

Gabriel: Yes, providers have many choices available to them as they consider the appropriate path for their practices to transition to revenue models that reward quality outcomes. MSSP, a permanent program launched via an act of Congress, remains the bedrock of Medicare value-based participation, with approximately 11 million Medicare beneficiaries enrolled in ACOs under that program.

The Affordable Care Act also created CMMI, extending a mandate to test new approaches that better align providers to the outcomes of their patients. These models include ACO REACH, Primary Care First, and the recently unveiled Making Care Primary model. Organizations like Pearl Health both help providers evaluate their options and enable their success upon enrollment. Each option has its own focus areas and strengths.

For instance, ACO REACH extends predictable cash flow in lieu of variable fee-for-service revenue, rewards providers that treat historically-underserved patient populations, and affords more risk exposure to participants. That means providers can benefit more from the quality and efficiency of care they deliver, but also may have to pay the government more if they fail to deliver results. This alignment to outcomes is critical for incentivizing the real investment and evolution our system requires.

Q: How is Pearl’s platform helping to engage providers in value versus insulating them from risk?

Michael: Ultimately, Pearl helps across both of these areas.

We facilitate engagement in value by making these programs available to the providers with whom we partner and deploying our proprietary technology platform to enable them to succeed in making this transition. The Pearl platform is purpose-built to help primary care providers manage their patients proactively in value-based programs. We aggregate data sources from across the healthcare system to power our Urgency Score, which prioritizes patients in need of outreach. We then explain (1) what signals we’re receiving that make us believe engagement is warranted, and (2) what action those signals indicate may be appropriate. Importantly, we’re giving prioritized visibility, so overburdened PCPs know when to engage, not how to practice medicine – they’re the experts there.

We also provide our partners with glide paths to more fulsome risk exposure. We recognize that they have been overburdened with administrivia and buffeted by the demands of the Covid-19 pandemic. We therefore think it’s critical to help practices make this necessary evolution in a stepwise fashion, and Pearl helps them get from A to B to C – across both financial and technological enablement.

Q: From the outside, it looks like Pearl is a ‘pipeline’ business focused on providing tools (technology, analytics, services) to primary care providers. At some point do you see an opportunity for Pearl to serve as a platform / marketplace connecting providers directly with payers (other than Medicare) who want to engage them in value based care arrangements?

Michael: Absolutely, that’s always been the intended trajectory. The US healthcare payor landscape is fragmented and, while Medicare remains the single largest payor and was therefore a logical starting point, we cannot make a meaningful dent in the systemic issues in US healthcare without offering value-based options in other payor verticals.

Pearl is expanding to Medicare Advantage by partnering with payors in this vertical, replicating as much as possible the constructs of ACO REACH and extending these structures to providers in the Pearl Network who wish to participate. Eventually, we foresee a world where the entirety of a primary care practice’s patient panel is accounted for in these outcomes-oriented constructs and Pearl’s technology is surfacing invaluable insights – and enabling critical workflows – across all patients.

Once we get there, Pearl network participants won’t have to think about what insurance a given patient has – or log into a slew of disjointed payor portals. We’ll do all of the administrative lifting on the backend so our provider partners can just focus on delivering quality, proactive and personalized care.

Q: Part of Pearl Health’s ethos is that specialization, like individualized physician enablement, is the key to achieving value-based care. With this in mind, how do you plan to scale your network, and do you have plans to go beyond primary care physicians serving Medicare populations?

Gabriel: While primary care providers are the quarterbacks of our healthcare system, and therefore the logical initial partners in our efforts to achieve change, there are many patients whose health conditions require specialized care and attention. Whether that’s a local cardiologist, or one of the many innovative specialized care delivery companies we reference in the Health Affairs piece, we can work with them through risk sharing arrangements that engender structural financial alignment. That alignment incentivizes these specialty partners to support our primary care partners in proactive patient management on a defined subset of the patient panel, providing wrap-around support without usurping the crucial patient-PCP relationship.

Over time, our platform can become the rails for this value-aligned network, irrespective of what Electronic Health Record a given practice is on, or whether they’re affiliated with a health system or enrolled in the local Health Information Exchange. We will also become increasingly sophisticated in our signal-action framework: depending on the actual patient need, a patient’s Urgency Score may indicate intervention seems warranted from a value-aligned pharmacist or oncologist, but not the primary care provider – or vice versa. Our platform is designed to accommodate that nuance and will increasingly allow this coordinated co-management.

Q: Studies have shown ACOs serving racially diverse populations fail at higher rates. According to new research published in JAMA Health Forum, ACOs treating a higher percentage of patients in racial and ethnic minority groups are much more likely to exit the MSSP than ACOs treating mostly white beneficiaries. What’s happening from an industry and technology perspective to make sure these groups aren’t left behind in the next phase of value-based care implementation?

Michael: Historically, ACOs have focused on more affluent populations. They tend to have stickier relationships with their providers (which tends to generate larger benchmark budgets) and have the financial stability to engage in longitudinal care management programs.

Addressing this reality is a priority for the Biden administration. The ACO REACH model has incorporated the Health Equity Benchmark Adjustment, which increases the benchmarks of ACOs whose providers treat historically underserved communities, incentivizing ACOs to recruit these providers and their patients. REACH also requires ACOs to collect patient-reported demographic and health equity data, to better inform analyses and future models.

As we referenced earlier, CMMI also just announced the Making Care Primary model, which will afford additional health equity-focused initiatives, including addressing health-related social needs, such as housing and nutrition. It will focus on Federally Qualified Health Centers, among other entities that provide important health and community support to underserved populations.