October 03, 2016|Categories: Models of Care
With the Centers for Medicare & Medicaid’s goal to transition half of all payments to value-based care models by 2018, and commercial payers following suit, the pressure is on for healthcare providers to move from traditional fee-for-service to fee-for-value payment programs. ACOs have taken up the gauntlet, but only about 25 percent of those that participated in Medicare’s Shared Savings Programs (MSSP) actually earned a performance payment last year. Meanwhile, Privia Health performed in the top 15 percent of ACOs in MSSP in the country, distributing bonus payments to all participating providers. We’ve learned that to really thrive under new payment models, there are at least three fundamental capabilities every provider group must have, as well as a technology partner to knit them together.
A Large Primary Care Network With a Shared Care Philosophy
Primary care physicians (PCPs) see about $.03 of every healthcare dollar, yet control most of the downstream costs. Value-based care is really simple math: How do you incentivize PCPs (and specialists who manage chronic patients) to eliminate unnecessary costs in the healthcare system?
To do this, you need a large network of like-minded, patient-centric PCPs. A few hundred doctors are no longer large enough. Payers are looking to sell narrow network products to their customers and need a large, high-performance network that can handle geographically dispersed employees. The larger the network, the easier it is for payers to underwrite the risk. This realignment of physicians and payers has created a huge opportunity for independent doctors to join high-performance medical groups.
Sophisticated Managed Care Contracting
Value- and risk-based contracts are significantly more complex than the fee-for-service contracting that most physicians are used to. If you don’t price the risk correctly, you can lose your shirt, as some doctors did in the 1990s. “Future-proofing” your practice requires alignment with a technology partner that can provide this core competency. You need deep expertise in the design of these programs, serious actuarial chops, and analytics departments that can help analyze the right deals, accurately track performance, and provide the insights needed to take out the unnecessary costs in the system.
A Single, Effective Population Health Platform
Removing unnecessary costs from the system is not an easy or inexpensive endeavor. Those who have been successful at delivering better outcomes at lower costs have typically worked off a single platform. At Privia Health, we needed a single, integrated solution that would empower us to compete at risk and provide high-quality healthcare without a hospital at the center.
A single EMR is a crucial requirement, as well as easy workflows that whisk work away from doctors for other clinical teams to accomplish. That platform needs to be connected to the larger healthcare eco-system of hospitals, payers, pharmacies, and labs. It should provide the connectivity necessary to know when patients are admitted or discharged from hospitals, and when they have failed to pick up their prescription; the ability to take action, like directly scheduling visits and reminders; and functionality to document and share information to improve quality metrics. You need personnel – care managers, pharmacists, behavior health experts, social workers – to work closely with patients in between office visits on a single shared platform. It’s hard for practices to develop these requirements on their own, without a trusted technology partner. At Privia, we’ve embraced a suite of integrated, cloud-based services from athenahealth to help us coordinate care inside and outside the exam room.
It is an exciting time in healthcare today. The realignment of physicians and payers creates a huge opportunity for independent doctors. Medical groups must coordinate their care across settings and look at their patient population as a whole – but that’s impossible without the right personnel and technology infrastructures. The opportunity is immense, but in our view, you can’t do it all on your own.
This piece originally appeared in Health Management Technology.