During the Nelson Mullins 2025 Annual Value-Based Care Forum, Navigating Opportunities in a Value-Driven World, virtual attendees submitted questions for the panelists to answer. Below are the panelists’ responses, which offer additional insight into the evolving value-based care landscape and its practical implications for health systems, payors, providers, and investors.

Keynote Address: 

Question 1: For “payment” in the survey, is that percentage of claims or dollars?

Juliette Price, Helgerson Solutions Group: Dollars

Question 2: Which model/category would PACE fit into?

Juliette Price, Helgerson Solutions Group: PACE is a full risk model, so it's Category Four

Panel 1: Where is the Money in VBC?

Question: What is the legal way on how to be able to remove a patient that is not coming to office visits and is causing expenses with frequent ER visits?

Kelly Conroy, Pinnacle Health: In my opinion, this is an issue with the provider. Patients don’t choose to be in ACOs (unless the voluntarily align themselves, it is the provider who joins an ACO). So if the patient isn’t coming in the provider needs to address this issue with the patient. Only when the patient is seen more (plurality of PCP services) by another PCP will the patient be assigned to another PCP service. There are a lot of nuances around attribution that should be addressed.

Ed White, Nelson Mullins: From a contracting perspective, a provider can ask to include language in their contract (with a health plan or ACO) to exclude patients who are not coming to the physician’s office (a “disengaged patient”). An example is a patient who has not been seen by the practice for the last 12 months. Your success will depend on the health plan or ACO and the leverage the group has to negotiate with the health plan or ACO. If the health plan or ACO pushes back, then you could ask for a care management fee to support outreach efforts to re-engage the patient. There is nothing to be lost by asking for these features in your provider agreement.

Panel 2: TEAMing Up: Using the Value-Based Enterprise with the new CMMI TEAM Program

Question: Are there incentive comp models that are not based on quality measures? Our health system’s culture/philosophy is that we “don’t pay extra for quality” or rather, quality is baked into or part of the care we provide.

Luis Argueso, In Health Advisors: A lot of the work required to succeed in VBC requires activities that are incremental to the typical provider workload. If your organization has the philosophy of not paying for quality because providers are expected to be high quality, I think it makes sense to frame the compensation incentives in terms of additional value-based care activities or duties. Let’s take TEAM as an example. A big driver of shared savings will be effective and judicious use of post-acute care resources. However, if you want to move directly to home care or manage down SNF LOS, your docs have to help you develop care protocols for doing so safely. They may need to interface with care navigation teams to make sure patients receive appropriate discharge instructions.

Further, they may need to work with the medical directors of home health and SNF organizations to give them comfort that less service utilization will not harm the patient. All of this requires work and is not a standard duty expected of a clinician. The incentive can be tied to meeting program development and monitoring milestones. Think of it like a medical directorship focused on value-based care and with payouts tied to hitting milestones (as opposed to paying based on hourly time sheets). I would emphasize an important point: the biggest effect of financial incentives is driving behavior on the margin. All physicians want to provide the best, highest quality care (I know this as the son of a surgeon). How I get paid drives where I will push myself to go the extra mile. In a wRVU-driven, fee-for-service world, that pushes physicians in the direction of performing more services. If that is not working well, it is worth considering a different approach.

If the discussion in the prior section seems like semantics, then you can consider tying incentives directly to shared savings pools. This would focus on measuring costs per episode by provider and rewarding the providers that effectively manage down their cost. I would also encourage you to require certain quality “gates” to be satisfied in order to pay out the shared savings (e.g., to earn shared savings, readmission rates must be kept below [x]%). That way you are not paying extra for quality but rather paying for shared savings that was earned by adhering to your organization’s quality standards. 

Question 2: Have you seen orgs use their ACO MSSP governing board to be the VBE board as well?

Ed White, Nelson Mullins: I have not seen an ACO MSSP use its board as a VBE board but it can certainly do so if it creates a VBE as part of the ACO. The important point is to make sure the VBE board is diligent in monitoring the VBE activities and ensuring there is progress on initiatives (or adjustments are made to the initiatives) to ensure the VBE participants continue to qualify for the modified Stark or Anti-kickback Statute rules. You can think of the VBE board as serving to fulfill a compliance function. One approach would be to use a portion of the ACO MSSP board as the VBE board to ensure you have people who will be committed to ensuring the compliance of the VBE.