"Crossing the Chasm"... of Value-Based Care

Is it still possible to get to > 80% adoption of value-based care in the US by 2030?

In a new piece in NEJM Catalyst (Free Access Link Here) renowned technology adoption expert Geoffrey Moore and I ask some provocative questions:

• Could it be that novel standalone CMMI models like Making Care Primary hindered mainstream adoption of VBC?
• Is the growth of ACO enablers a problem to be fixed, or a solution to be embraced?
• Are ACOs the vanguard where tough new standards should be imposed?
• Should policy attention now focus on growing specialist participation in VBC?

Here are some lessons gleaned from his seminal work "Crossing the Chasm" and my own experience leading the nationwide adoption of Electronic Health Records from 2009 to 2014, when we went from 22% to 74% of office-based physicians using at least a basic EHR.

"The term chasm here refers to the gap in a market between the early adopters of new innovations and the remaining customers who retain traditional methods or technologies. Generally speaking, the early adopters lean in because they believe in the cause or the potential value of the technology to their business, and are willing to make sacrifices (or take risks) to further its goals and values (or strengthen its place in the market by some key metric). By contrast, the bulk of the market in the incumbent mainstream prefers to take a wait-and-see approach. To get this group to adopt and, ultimately, create a new mainstream featuring the new model, sponsors of change must create a compelling reason to act."

1) Focus on a Niche Market (Go Deeper with Primary Care) In order to leap the chasm in technology adoption, you need to focus the magnifying glass on an initial niche market that will be the first segment of mainstream adopters and use that as a base for broadening

2) Define the Competition (Fee-for-Service Is Bad — for Patients, Practices, and Society) There must be no question that, as far as the government is concerned, unfettered fee-for-service is bad for beneficiaries and bad for Medicare (and will therefore be disincentivized for providers as well). The alternative to accountable care should be a clearly inferior choice.

3) Switch from Bells and Whistles to Proven Solutions (MSSP Is the Chassis). Most health care providers are not looking to be innovators or to participate in pilot tests; they want to participate in standard offerings and core programs. In fact, a constant flow of new models and options gives pause to pragmatists.

4) Assemble the Whole Product (Cover the Whole Patient Panel). CMS must extend its goal for accountable relationships to beneficiaries enrolled in Medicare Advantage plans and provide incentives for plans to achieve this goal — perhaps through the Quality Bonus Program’s five-star rating system.

5) Make Space for the Simplifiers (Tap into Physician Enablers). Late adopters are not do-it-yourselfers; they want to minimize time spent on installation and technical implementation and rely instead on the work done and lessons learned by service providers with earlier experience and relevant expertise.

Here's how we ended:

Put simply, what primary care practices fear in transitioning to value-based care must be made less onerous than what they should fear from the fee-for-service status quo. Because if we fail to cross this chasm, to create a new value-based mainstream, we risk a bleak future in which our health care system continues to deliver substandard care at a high cost, and primary care continues to atrophy. Our aging population needs and deserves a better future.