AAFP Guiding Principles for Value-Based Payment

Family physicians deliver most of the primary care in the U.S. It is essential that they and other primary care physicians take a leadership role in the development of policies and practices that facilitate movement away from fee-for-service and toward new advanced primary care payment models along with other key stakeholders, such as purchasers, union trusts and government (federal and state) agencies responsible for U.S. health care spending.

These principles are intended to be responsive and adaptable to the changing environment and settings in which family physicians work. We encourage others to use these principles with the understanding that they must be applied in ways that are:

1. responsive to community needs, preferences, and resources,
2. adaptable to different practice organizational models, structures of care and physician specialties,
3. inclusive of individual patient preferences and socio-cultural backgrounds, and
4. sensitive to differences in adoption of health information technology while encouraging its effective spread and connectivity.

Value-based payment is designed to support collaborative partnerships between patients and physicians that include the four key functions of primary care (first contact access, comprehensiveness, coordination, and continuity), which are essential to meeting the goals of improved quality and reduced health care spending. As more AAFP members transition to providing value-based care, these principles are intended to guide the design and implementation of value-based payment models which support a healthcare system grounded in strong primary care that improves health outcomes, contributes to eliminating inequities, and reduces future health care spending.

The success of these principles is highly dependent on alignment across payers. Value-based payment models are unlikely to work if only a small subset of a practice's patient population is included. Covering just a portion of patients with value-based payment while the balance remains in traditional fee-for-service does not provide the level of prospective payment needed to invest in building advanced functions of primary care required for excellent population management.

• Value-based payment (VBP) models should be aligned across payers and provide predictable, prospective revenue streams as a foundation to sufficiently support comprehensive, longitudinal, patient-centered, high-value care in addition to performance incentives that reward improvement as well as sustained performance against financial and quality benchmarks. Within practices and other healthcare organizations, individual physicians should share in the financial rewards that accrue from their performance.
• Methodologies used to determine the patients for which physicians and care teams are held accountable must prioritize existing patient-physician relationships over less reliable claims or geographic methods while ensuring physicians and primary care teams have reliable, timely information about the patients for whom they are held accountable.
• Risk adjustment methodologies should incorporate clinical diagnoses, demographic factors, and other relevant information such as social determinants of health without exacerbating healthcare disparities or expanding the administrative burden on primary care practices. Social determinants of health should be identified as risk factors and used for risk adjustment of populations. Primary care physicians cannot be held accountable for providing resources to address social determinants of health that do not exist in the community.
• Financial benchmarks in VBP models should incentivize high-quality, efficient, accountable care delivery by establishing targets that reward both improvement and sustained performance over time.
• Performance measures should focus on processes and outcomes that matter most to patients and have the greatest impact on overall health, and unnecessary spending. VBP measures, as well as the mechanisms of measurement, should be parsimonious and aligned across payers to reduce unnecessary administrative burden.
• Clinically relevant and actionable patient information should be readily available in a timely, accurate, secure, and efficient manner that does not place unnecessary administrative or financial burdens on primary care practices. (JULY 2022 BOD) (September 2022 COD)