Cat 22 0123

COMMENTARY
Global Horizons for Value-Based Care:

Lessons Learned from the Cleveland
Clinic
Chibueze Okey Agba, MBA, Joshua Daniel Snowden-Bahr, JD, MHA, Kushal T. Kadakia, MSc,
Samer Abi Chaker, MD, MPH, James B. Young, MD, Alex G. Forystek,
DOI: 10.1056/CAT.22.0123
As global health care expenditures continue to rise due to aging populations and managing
chronic diseases, providers, payers, and policy makers must shift their focus from
traditional fee-for-service models to value-based care programs. Despite early progress
in the value space, there have been delays in implementation to stand up value-based
programs due to transition costs and changes to infrastructure, as well as varying health
care infrastructure capabilities across the globe. This article reviews the Cleveland Clinic’s
unique experience developing, operating, and refining value-based care models in the
United States and the United Arab Emirates, with early applications and lessons learned
in the United Kingdom, using these case studies to extrapolate challenges, successes, and
opportunities for implementing global value-based care models.
Rising health care expenditures coupled with evolving patient needs have generated a global
impetus for health care reform. As the public sector bears an increasing proportion of costs, policy
makers and health system leaders have sought to identify financing arrangements and care delivery
strategies capable of reducing costs and improving population health.1
For example, in the United States (U.S.), the Affordable Care Act supported the development
of payment models designed to incentivize quality and improved outcomes.2 The United Arab
Emirates (UAE) introduced a prospective payment system to improve efficiency and enable
performance comparisons across different hospitals.3 In the United Kingdom (UK), the Five Year
Forward View called for investment in “new care models” to support service integration.4
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These different reforms share the common goal of promoting high-value health care, with the best
possible outcomes per dollar spent. Translating value-based care from theory into practice remains
challenging. Research evidence is still emerging and there is no consensus on an optimal approach.
From Michael Porter’s six interdependent and mutually reinforcing components in a high-value
health care delivery system5 to a recent European publication’s identification of eight mandatory
components to implement value-based health care in a hospital, proposed models differ based on
elements and regional applications.6
Obstacles are numerous, ranging from misaligned incentives resulting from fee-for-service
payment structures, to infrastructure gaps, to burdensome regulations.7 Successful models
often rely on payer-provider partnerships and leverage system-level capabilities.8 By changing
reimbursement, providers and payers can redefine what services are considered valuable,
supporting reductions in unnecessary utilization and improvements in care coordination.
However, payers and providers face barriers to coordination. Providers may operate in
incompatible payment environments, simultaneously trying to fulfill the requirements of both fee-
for-service and value-based contracts, where financial incentives (payment for service volume vs.
payment for “value”), expectations (e.g., financial risk), and capabilities (e.g., data sharing) differ
depending on the type of contract. Providers must reduce expenditures while still retaining the
fixed costs of legacy infrastructure, which remains fragmented by specialty rather than integrated
according to patient needs and evidence-based clinical guidelines. Nevertheless, the experience
of successful payer-provider partnerships reveals a basic truth about health care innovation: while
good intentions can spark change, strong incentives enable change to last.
Although the literature offers examples of promising care delivery models,9 evidence is lacking
on how to design, implement, and sustain payer-provider partnerships in international markets,
including infrastructure investments, operational changes, and contractual best practices. The
Cleveland Clinic Foundation — a physician-led health system with a century-long history of
supporting innovative, integrated, patient-centered care — has sought to establish value-based care
models in distinct clinical and cultural settings. This article uses case studies from Cleveland Clinic
sites in the U.S. and the UAE to share lessons learned for systems transitioning to value-based care.
Global Case Studies

The Cleveland Clinic is a globally integrated academic health system dedicated to “caring for life,
researching for health, and educating those who serve.” Cleveland Clinic is a 6,690-bed health care
system with 22 hospitals and 226 outpatient locations. The system is comprised of 15 hospitals in
northeast Ohio, including the 1,294-bed main campus; five hospitals in southeast Florida totaling
more than 1,000 beds; a center for brain health in Las Vegas; two outpatient facilities in Toronto; a
394-bed hospital in Abu Dhabi and outpatient facility in Al Ain, UAE; and an outpatient facility and
184-bed hospital in London.
Each new Cleveland Clinic site seeks to align with this mission, from partnering with payers and
policy makers to meet the unique needs of each population, to advancing innovation for the most
complex diseases, to recruiting and nurturing local talent for the future. Orienting each system
NEJM CATALYST 2
Table 1. Summary of Case Studies
Domain Cleveland Clinic Medicare ACO (CCMACO) Cleveland Clinic Abu Dhabi (CCAD)
Health System •Launch Date:2015 •Launch Date:2015
Overview •Scope:Population health program across regional hospitals •Scope:364-bed hospital serving >1,600,000
and family health centers serving >148,000 Medicare bene- covered lives
ficiaries and >280,000 in 10 commercial shared savings/val- •Focus:Complex specialty care
ue-based agreements
•Focus:Comprehensive primary care, transitional care man-
agement
Health Policy •Country:United States (Ohio) •Country:United Arab Emirates (Abu Dhabi)
Environment •Regulatory Changes:Affordable Care Act (2010); Medicare •Regulatory Changes:Mandatory Insurance
Shared Savings Program (ACOs) (2011); Price Transparency (2006); Adoption of DRGs (2012); Pay-for-Per-
(2019) formance (2017); Reimbursement Reform
(forthcoming 2023)
Value-Based • Payment model includes two-sided financial risk • Centers of Excellence for high-priority con-
Elements • Provider-designed quality measures ditions
• Independent governance structure • Interoperable electronic medical record to
track utilization and outcomes
• Pay-for-performance model
• Narrow networks
Key Case Study • Value is a journey, not a destination • Regulatory change can be a tailwind for health
Lessons • What you measure is what you value system transformation
• Partnerships are key • Coding integrity is essential to value-based care
• Diffusion of innovation begins with diffusion
of culture
ACO = accountable care organization. DRG = diagnosis-related group. Source: Cleveland Clinic
around this mission has enabled Cleveland Clinic to advance value-based care around the world. In
this section, we present case studies for how Cleveland Clinic established a value-based model in
the U.S. and successfully translated it to the UAE. We also share early learnings for adoption in the
UK (Table 1 and Figure 1).
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FIGURE 1
Case Study 1: Cleveland Clinic Medicare Accountable Care

Organization (U.S.)
Model Overview
Cleveland Clinic’s Medicare Accountable Care Organization (CCMACO) covers more than
148,000 beneficiaries in northeast Ohio. Participating provider organizations include Cleveland
Clinic’s main campus and regional hospitals, the Cleveland Clinic group practice, and independent
primary care physicians affiliated with the Cleveland Clinic Quality Alliance. Multidisciplinary care
teams form the core of CCAMCO’s outpatient chronic disease management program, with these
providers connected by investments in information technology (IT) and collaborative governance
between patients, providers, and payers.
“ Evidence is lacking on how to design, implement, and sustain

payer-provider partnerships in international markets, including
infrastructure investments, operational changes, and contractual
best practices."
NEJM CATALYST 4
Policy and Market Context
CCMACO is part of the Medicare Shared Savings Program (MSSP), America’s largest alternative
payment model. MSSP seeks to realign incentives by delineating financial risk and performance
on a series of defined quality metrics. Health systems participating in MSSP form accountable
care organizations (ACOs), with providers accepting accountability for outcomes and costs for a
defined population. ACOs report their performance on quality and are eligible for shared savings
if providers’ expenditures are below a given benchmark. ACOs can elect to participate in different
“tracks” of financial risk within MSSP, with regulators encouraging ACOs to gradually assume more
risk.10
CCMACO Timeline
Cleveland Clinic joined MSSP in 2015. Because patient attribution for the ACO program occurs
at the primary care physician level, Cleveland Clinic formed a separate legal entity to foster
partnerships with independent primary care providers in Ohio. The resulting entity, Cleveland
Clinic Medicare ACO, LLC, also established governance structures designed to reflect CCMACO’s
commitment to continuous improvement. For example, the governing body includes a Medicare
beneficiary to incorporate an active patient voice during decision-making. Both independent
and employed physicians serve as representatives on the Quality Committee and Financial
Committee. Operationally, CCMACO has developed a team-based model comprising primary care
coordinators, population health medical assistants, transitional care management hub caregivers,
pharmacists, and social workers. This multidisciplinary approach, informed by the “team of teams”
culture of Cleveland Clinic’s institute model, focuses on managing care transitions to reduce
unnecessary utilization.
CCMACO initially only assumed upside risk under MSSP’s Track 1. The program showed promise
from the outset, achieving $42.2 million in savings (of which Cleveland Clinic kept 3%) and a
quality score of 96.3% by 2016.11 This foundation for value prepared Cleveland Clinic to transition
to downside risk, entering Track 1+ in 2018.12 Under this program, ACOs become eligible for
shared savings up to 50% in exchange for a fixed loss sharing rate of 30%.13 By 2020, the final
quality score exceeded 98.1% with $9.56 million in savings. Of this sum, 75% was distributed to
ACO participants, 15% was invested in infrastructure, and 10% was invested in redesigned care
processes and resources.
Lessons from CCMACO later informed the dissemination of value-based care principles to
Cleveland Clinic Florida, which established its own ACO model in 2018 that currently encompasses
nearly 36,000 beneficiaries in a one-sided risk model. Cleveland Clinic Florida maintains select
contracts with limited downside risk (AvMed and Florida Blue), and it will expand its ACO to
downside risk once it further enhances its operating model and capabilities.
Challenges and Lessons Learned

1. Value is a journey, not a destination. Cleveland Clinic already had many of the ingredients
of value-based care: physician salaried employment model, integrated financial management
NEJM CATALYST 5
platform, interoperable electronic medical records, culture of improvement, and ethos of
innovation. However, piecing together new payment and delivery models requires thoughtful
planning and collaboration, and a willingness to challenge norms for how care is governed and
delivered. To this end, CCMACO convened different stakeholders to develop the governance
models, legal arrangements, and care teams that would assume accountability for the ACO
population. CCMACO’s leadership also developed a phased approach for titrating financial risk
from Track 1 to Track 1+, therefore transitioning from upside risk only to both upside and downside
risk,13 to provide sufficient space for the model to achieve “wins” (that is, demonstrate shared
savings) and make adjustments (e.g., new partnerships).
2. What you measure is what you value. Well-designed performance measures provide
valuable insight to providers and system leaders about areas for improvement and investment.
However, measures must be rooted in outcomes that matter to patients. Metric development
should be a collaborative process accounting for both physician and patient perspectives.
CCMACO incorporated this principle into its contracting mechanism, creating a formal Quality
Committee within the ACO legal entity that included both employed and independent physicians.
This cocreation process fostered accountability, while investment in enterprise analytics created
mechanisms to track and measure performance. To supplement the primarily process-based ACO
quality measures, CCMACO invested in quantifying the patient experience through the use of
rigorously designed patient surveys, the creation of an advanced patient registry, and focusing on
patient experience through leadership rounding and continuous improvement projects led by a
physician Chief Experience Officer.
“ Piecing together new payment and delivery models requires

thoughtful planning and collaboration, and a willingness to
challenge norms for how care is governed and delivered."
3. Partnerships are key. Value is achieved, or lost, at the margins of care delivery:
hospitalizations, procedures, discharges, follow-ups, and care transitions. Team-based models
and partnerships help to close gaps in the care continuum. For example, CCMACO created
a Transitional Care Management Hub, where caregivers focus on preventing readmissions
by coordinating patient handoffs back to their primary care provider and collaborating with
pharmacists to provide services such as medication reconciliation. CCMACO also partnered with
other care delivery organizations in the region. We included independent primary care practices in
the Cleveland Clinic Quality Alliance, and partnered with high-quality skilled nursing facilities to
reduce length of inpatient stays.14
Case Study #2: Cleveland Clinic Abu Dhabi

Model Overview
Cleveland Clinic expanded its international footprint in 2015 by opening a hospital in the UAE.
In contrast to CCMACO’s primary care focus, Cleveland Clinic Abu Dhabi (CCAD) focused on
NEJM CATALYST 6
introducing technological and clinical innovations for specialties such as cardiac, transplant, and
neurological care. CCAD also leveraged the new “institute” model of Cleveland Clinic, with care
organized around multidisciplinary teams for diseases and organs rather than traditional academic
departments. To expand coverage for new treatments and service lines and support payment
system modernization, CCAD collaborated closely with the Departments of Health and Finance,
and public and private insurers. As of December 2021, CCAD has completed over 3.2 million
outpatient visits, 94,000 surgeries and served 312,000 unique patients from over 80 countries.
Policy and Market Context

CCAD’s creation occurred amidst significant health system reform in the UAE, including the
development of mandatory health care coverage and the adoption of prospective payment
methodologies. The Emirati population has faced a growing disease burden exacerbated by gaps
in specialty care, particularly for complex procedures, resulting in increased costs for both payers
and the Department of Health. Together, the competitive market, evolving policy landscape,
and opportunity to reduce pressure on public budgets and improve population health outcomes
presented a unique environment for value-based care.
CCAD Timeline
CCAD is a joint venture between Cleveland Clinic and Mubadala Investment Company that
employs physicians from more than 55 sub-specializations in its 14 institutes (including 6 centers of
excellence). In addition to expanding specialty care capacity, CCAD also introduced innovations
across many diseases. For example, CCAD became the market leader for services in cardiology
(e.g., transcatheter aortic valve replacement) and digestive disease (e.g., robotic-assisted subtotal
pancreatectomy). CCAD has demonstrated great ability to provide high-quality care for patients
with severe illness and conditions, treating a patient population with a case mix index (CMI) of
3.73 by the end of 2021.15 (CMI represents a relative value assigned to a diagnosis-related group
of patients in an inpatient setting.15 It is used in determining the resources required to provide
care, and thus gives an indication of level of acuity. By comparison for year-end 2021, the CMI for
Cleveland Clinic was 1.94,16 with the Medicare CMI for Main Campus being 3.02.17)
Contracts with the government and key private insurers helped establish CCAD’s base population,
which by 2019 exceeded more than 1,000,000 covered lives, the majority of whom were Emirati
nationals.
Despite strong clinical outcomes and patient satisfaction rates, CCAD encountered financial
challenges, due in part to the introduction of novel treatments and technologies (for which
patients previously traveled overseas) beyond the scope of existing payment policies. To address
these challenges, CCAD collaborated closely with regulators to support reimbursement reforms.
For example, the Department of Health relied for years on the 2011 code set version for Current
Procedural Terminology (CPT), which meant that many new procedures which CCAD offered
were either absent or miscoded. The 2021 implementation of the 2018 code set is a step forward for
modernizing reimbursement but still will reflect delays in most accurate coding.18
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Likewise, the shift from inpatient to outpatient cases required engagement regarding Abu Dhabi’s
payment methodology, which reimburses same-day procedures through per diem charges,
inpatient encounters through international refined diagnostics-related group (IR-DRG) payments,
and outpatient visits through fee-for-service. For instance, service code specifications required
patients to be admitted for more than 12 hours to account for markedly higher DRG reimbursement
given that per diems did not allow hospital additional reimbursement for pathology, secondary
procedures, consumables, and prostheses. Under this system, potential financial misalignments
could discourage clinical innovations that could offer benefits for safety, effectiveness, and
convenience.
“ Metric development should be a collaborative process accounting for

both physician and patient perspectives."
Additional reimbursement reforms are ongoing, and CCAD continues to prominently partner with
the government to advocate sustainable solutions using the hospital’s 7 years of data reflecting
tertiary-quaternary care delivery (e.g., extracorporeal membrane oxygenation [ECMO] and
transplants). Through July 2022, the Abu Dhabi Department of Health continues to use feedback
from providers and payers to iterate its reimbursement system, including: changes to episode
definitions; DRG pricing and weights; and adjustment mechanisms, both for quality-based
institutional metrics and for outlier cases.
Challenges and Lessons Learned

1. Enabling regulations and strategies at the health-system level is essential for value-
based care. Abu Dhabi’s health care reforms were instrumental in incentivizing new care delivery
models. While the regulatory environment continues to evolve, Abu Dhabi pushes for improved
performance and collaboration between payers, providers, and policy makers. CCAD capitalized
on this emphasis to navigate new terrain and improve access and outcomes. CCAD’s experience
illustrates how genuine payer-provider partnerships are necessary to modernize coverage policies
and expand service offerings according to population needs. For example, CCAD has engaged
payers and regulators on Abu Dhabi’s new JAWDA program (Arabic for “quality”), which contains
guidelines covering 19 services including pivotal offerings such as one-day procedures, cardiac
surgery, and stroke.
2. Coding integrity is essential to value-based care. Value does not exist in a vacuum; the
unique needs of patients determine definitions. Consequently, payment systems must be calibrated
to account for differences in individual care needs and the population’s disease burden to ensure
appropriate resource allocation. CCAD has the UAE’s highest case-mix and has introduced novel
procedures and technologies to advance specialty care. Partnerships with payers and ongoing
dialogue with regulators have enabled meaningful progress in coding and claims processing,
including coverage for germline/somatic testing for oncotype diagnosis of breast cancer and
pharmacotherapy consultations for heart failure and post-transplant patients. CCAD’s experience
illustrates how sustainable financing for clinical innovation requires aligning incentives across
NEJM CATALYST 8
contracting and coverage policies to support a checks-and-balances approach to billing. Regular
engagement among CCAD, payers, and regulators has also allowed better measurement of episodic
costs through appropriate coding alignment.
3. Diffusion of innovation begins with diffusion of culture. While delivery models are
portable, the “secret sauce” of culture and continuous improvement can prove challenging to
replicate. CCAD leveraged enterprise capabilities to translate the Cleveland Clinic’s three-pronged
culture of patient care, scientific research, and clinical education to the UAE. First, CCAD adopted
the same employment (salaried physicians) and organizational model (clinical institutes). Second,
CCAD used the same electronic medical record as Cleveland Clinic’s main campus, enabling
replication (with localization) of care processes. Third, many members from various levels of
organizational hierarchy at CCAD came directly from Cleveland Clinic, providing continuity
in leadership and vision. Seeding the new system with U.S. leaders helped instill the Cleveland
Clinic culture of “patients first” at CCAD and support the system’s integration into the global
Cleveland Clinic enterprise. Importantly, CCAD also recruited health care leaders from the UAE
to its leadership team and hired hundreds of Emirati nationals from both the local community and
abroad. Lastly, CCAD also invested in graduate medical education in the UAE to develop a pipeline
for future talent.
Future Applicability for Cleveland Clinic London

Cleveland Clinic London (CCL) is the latest international footprint expansion of the Cleveland
Clinic health system. CCL consists of an outpatient medical office building that opened in
September 2021 and completed 38,000 appointments with 13,000 unique patients within its first
9 months. In March 2022, CCL opened a 184-bed hospital in Central London for privately insured
UK and overseas patients, including 29 intensive-care beds — the highest proportion of ICU beds of
any hospital in the area.19 Its opening represented years of a complex construction and activation
timeline impeded by Covid-19 and Brexit. In its first 2 months, the hospital completed over 545
same-day procedures and surgeries, and 293 inpatient admissions.
As CCL has only recently started serving patients, data-informed lessons learned would be
premature, although CCL started regularly engaging payer and regulatory partners 5 years prior to
launching clinical operations. We identify two takeaways from this process:
First, given the long lead time on IT system enhancements and the complicated multi- and
interdisciplinary nature of integrated care pathways, CCL initiated internal designs of care paths
across IT, clinical institutes, allied health professions, safety and quality, and finance teams in
2018. CCL started sharing symptom-based pathways with payers in 2019 to secure stakeholder
partnership and collaboration.
NEJM CATALYST 9
“
Abu Dhabi pushes for improved performance and collaboration
between payers, providers, and policy makers. CCAD capitalized
on this emphasis to navigate new terrain and improve access and
outcomes."
Second, new market entrants do not have their own historical data to use for benchmark
comparison. While value-based care is nascent in the UK, CCL is leveraging enterprise analytics
and codifying data exchanges and collaboration with payers from past experiences in the U.S.
and the UAE to demonstrate de novo the potential cost savings from a new value-based model.
CCL has incorporated value-based review mechanisms into its payer contracts, creating legal and
operational structures to codevelop measures, exchange and review performance data to drive
systematic improvements, and execute charge adjustments accordingly based on theoretical
projections stemming from payers’ historical utilization and agreed pricing with CCL.
Discussion
Health care as an industry has at least a theoretical commitment to continuous improvement.
However, one must distinguish between activities that are value-added and models that are value-
based, with value previously defined as outcomes per dollar spent.5 As illustrated in Figure 2, value-
based care models must be patient-centered, with cost, quality, and outcomes mediated by the
relationship between providers and payers. Each entity contributes respective enablers for value.
A provider’s culture and governance, care model and pathways, costing capabilities, and digital
and technology functions represent enablers on the delivery side, whereas the payer’s population
profile, financial model, evaluation capabilities, and digital and technology functions function
as the enablers on the payment side. These interactions are further influenced by the policy and
market environment in the provider’s location.
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FIGURE 2
These case studies illustrate how carefully designed and well-executed payer-provider partnerships
help deliver value-based care in different clinical and cultural contexts. Table 2 summarizes
examples from the case studies for each of the enablers of value-based care models presented in
Figure 2. For example, the care pathways model for CCAD represents a unique enabler for value-
based delivery in the Abu Dhabi market. Likewise, the CCMACO value-based steering committee
provided an organizational culture and governance of empowering physicians to serve as leaders
and cocreate the quality measures for which they would later be held accountable. On the payment
side, the evaluation capabilities of the Department of Health in Abu Dhabi enabled the transition to
prospective payment and pay-for-performance.
The profile of the insured population also frames the orientation of care delivery. For instance,
because most Medicare patients are age 65+ and often have multiple chronic diseases, payers
needed to calibrate financial incentives and quality measures around improving disease
management. CCMACO’s emphasis on primary care and population health impacted this
important aspect of the patient journey.
Collaborations among regulators, providers, and payers were critical for navigating local policy and
market environments. For example, CCAD had to work with regulators on updating coding and
coverage policies for novel technologies to address tertiary-quaternary care gaps that previously
resulted in longer episodic costs or Emiratis receiving more expensive treatment outside of their
home country.
NEJM CATALYST 11
Table 2. Value-Based Enablers from Case Studies
Enablers of Value-Based Care Examples from Case Studies
Enablers: Delivery Culture and Gover- Leadership CCMACO and CCAD focused on integrating each delivery model into
nance the global Cleveland Clinic system through shared governance and common values
Care Model and CCAD developed symptom-based care standardized pathways to reduce unneces-
Pathways sary utilization
Costing Capabilities CCAD developed pricing proposals to support the modernization of coverage and
coding systems with payers
Digital and Tech- All Cleveland Clinic care sites used an integrated electronic medical record to
nology enable seamless care coordination
Enablers: Payment Population Profile Medicare patients are elderly and generally have multiple chronic conditions;
consequently, CCMACO focused on integrating primary care and population health
functions
Financial Model Abu Dhabi implemented new payment incentives for value, driving CCAD to adjust
payments according to performance
Evaluation Capa- Medicare measures performance on defined quality metrics; hence, CCMACO had
bilities to share data and perform relative to these established benchmarks
Digital and Tech- CCAD and UAE-based payers engaged in sharing data on utilization to identify
nology opportunities for efficiency improvements
CCMACO = Cleveland Clinic Medicare Accountable Care Organization. CCAD = Cleveland Clinic Abu Dhabi. Source: CAPADEV LLP and
Cleveland Clinic
As the value-based care framework in Figure 2 and the examples in Table 2 demonstrate, strategic
planning, early investment in governance models (including steering committees and clinical
institutes), and a long-term commitment among all parties can propagate care models to achieve
the shared goals of better outcomes at a lower cost — even in environments new to value-based care
and payer-provider partnerships. To illustrate the generalizability of Cleveland Clinic’s experiences
designing, building, and sustaining value-based care models, we offer the following four cross-
cutting lessons.
Proactively Plan to Streamline Implementation

Engaging with policy makers to help streamline regulations is critical to guide hospital networks’
approach to new geographies. For example, in the UK, a Competition and Markets Authority
investigation illustrated the need for new entrants,20 while in the UAE, a focus on reducing the
need for UAE nationals and residents to travel overseas to receive complex treatment21 preceded a
drive to operate under prospective environments and introduce tertiary-quaternary care provisions.
Likewise, clinical offerings must be tailored to the unique needs of the population.22 Health systems
can streamline international expansion by focusing their engagement strategy (with groundwork
with payers and referral pathways made well in advance). As health systems define their place
in the market, they may need to further define the boundaries of their engagement. No provider
can do everything, or at least do everything well, so providers should clearly define the use cases
and service offerings timely to avoid assuming unnecessary fixed costs. This journey requires
commitment to long-term planning with clearly defined milestones to provide space for transition
costs and growing pains. In doing so, health systems can nurture collaborative, sustainable
approaches to introduce value-based care.
NEJM CATALYST 12
“
Value-based care models must be patient-centered, with cost, quality,
and outcomes mediated by the relationship between providers and
payers."
Establish a Governance Model for Value-Based Care

For value-based models to succeed, providers must clearly define and refine responsibilities,
governance models, and terms of engagement when contracting with payers. The case studies
illustrate the importance of inclusive and empowered governance models to foster accountability
and drive decision-making. For example, CCMACO developed a formal legal entity for the ACO
that included representation from independent providers who had entered into a partnership with
Cleveland Clinic, enabling providers to support designing the performance measures for which
they would ultimately be accountable. Likewise, CCL from the outset has included committee
structures in its contracts with payers with details proposing representation, developing meeting
structures, and identifying action items.
Develop Infrastructure and Frameworks for Data-Driven Decision-Making

Infrastructure for data collection and exchange requires proactive development. For example,
Cleveland Clinic has used the same electronic medical record platform at each of its care sites,
creating global connectivity. Likewise, developing the capacity to share data across platforms and
review progress at regular intervals will strengthen the partnership between payers and providers.
Providers may possess key data on clinical metrics (e.g., hospital-acquired infections), while payers
may possess key data on utilization metrics (e.g., referral experience for patients).
In practice, payers and providers often only meaningfully engage during renewals and
reconciliations, times that naturally can lead to heated debate and confrontation. Sharing
actionable data transforms a payer-provider orientation around those two contentious “R’s” —
renewals and reconciliations — and adds a third “R” for regular relationships.23 The relationship
evolves through three phases: from payment for reporting to payment for performance and
ultimately to payment for value. By holding frequent meetings driven by payer scorecards
indicating mutual key performance indicators (KPIs), relationship and trust is cultivated personally
and professionally along this journey.
From an implementation perspective, data sharing may pose complications, and may require
navigating regulations on patient privacy (e.g., HIPAA in the U.S., the EU General Data Protection
Regulation, and the UK’s own adoption of GDPR and Data Protection Act, as may be further
amended post-Brexit). Solving for these challenges from the outset prevents future roadblocks.
Lastly, not all data is made equal: measurements should be relevant, timely, informative, and
actionable. Providers and payers should create dashboards with KPIs from agreed sources of truth
to measure progress and guide decision-making.
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Focus on the Whole Patient Journey
As Cleveland Clinic has evolved from predominately a provider of surgical, complex specialty
care to a more population health–oriented system, a better understanding of a patient’s full
care journey has revealed untapped potential for improvements in the pre- and post-treatment
phases.24 Lessons learned through its CCMACO care navigation coupled with its own experiences
as a narrow network self-insured employee health plan have allowed Cleveland Clinic to develop
playbooks for success factors with commercial value-based contracting. To shift payer-provider
financial alignments, providers need mechanisms incented and funded by payers to cover
preventive services such as proactive screening and clinical management.
Cleveland Clinic has worked collaboratively with a number of payers to implement value-based
programs that include performance metrics and quality indicators handed down by the U.S.
Centers for Medicare & Medicaid Services (CMS). The metrics put in place are designed to
incentivize providers to reduce utilization, thereby decreasing spending. Metrics can be calculated
on an annual, per occurrence, or historical performance basis, and can be tied to quality incentive
payments or shared savings payments. Metrics range from medication adherence to average length
of stay to cancer screenings to readmissions.25
Interest in value-based care will continue to grow as health care reforms accelerate around
the world. While payment and delivery reforms are the primary focus of value-based care, it
is necessary to acknowledge the important roles of suppliers, drug and device makers, and IT
developers, all of which are beyond the scope of this article. Nevertheless, the global case studies in
this article offer lessons for health care leaders from our efforts to design, implement, and sustain
partnerships in different international markets. Although the nuances of challenges and solutions
for health care innovation will differ, the overarching goal should remain the same: deliver value as
defined and measured ultimately with the patient at the center.
Chibueze Okey Agba, MBA

Chief Financial Officer, Hartford HealthCare, Hartford, Connecticut, USA
Joshua Daniel Snowden-Bahr, JD, MHA

Regional Director, Contracting & Business Development (International Markets), Market &
Network Services, Cleveland Clinic Health System, Cleveland, Ohio, USA
Kushal T. Kadakia, MSc

MD Candidate, Harvard Medical School, Boston, Massachusetts, USA
Samer Abi Chaker, MD, MPH

Health Care Program Leader, CAPADEV LLP, Dubai, UAE
James B. Young, MD
Executive Director of Academic Affairs, Cleveland Clinic, Cleveland, Ohio, USA Professor of
Medicine & Vice Dean for Academic Affairs, Cleveland Clinic Lerner College of Medicine, Case
Western Reserve University, Cleveland, Ohio, USA
NEJM CATALYST 14
Alex G. Forystek,
International Payer Contracts Manager, Cleveland Clinic, Cleveland, Ohio, USA
Disclosures: Chibueze Okey Agba, Joshua Snowden-Bahr, Samer Abi Chaker, Kushal T. Kadakia, James B.
Young, and Alex G. Forystek have nothing to disclose.
References
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COMMENTARY

Global Horizons for Value-Based Care:

Global Case Studies

Case Study 1: Cleveland Clinic Medicare Accountable Care

“ Evidence is lacking on how to design, implement, and sustain

Challenges and Lessons Learned

“ Piecing together new payment and delivery models requires

Case Study #2: Cleveland Clinic Abu Dhabi

Policy and Market Context

“ Metric development should be a collaborative process accounting for

Challenges and Lessons Learned

Future Applicability for Cleveland Clinic London

Proactively Plan to Streamline Implementation

Establish a Governance Model for Value-Based Care

Develop Infrastructure and Frameworks for Data-Driven Decision-Making

Chibueze Okey Agba, MBA

Joshua Daniel Snowden-Bahr, JD, MHA

Kushal T. Kadakia, MSc

Samer Abi Chaker, MD, MPH

5. Porter ME. What is value in health care? N Engl J Med. 2010;363(6):2477-81

17. American Hospital Directory. The Cleveland Clinic Main Campus.

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