At a time when issues around taking on risk-based contracts are becoming more complex and challenging for physician groups, some physician organizations are moving ahead to lay the foundations for success in risk-based contracting, all of which require strong health risk assessment processes around broad covered populations, and the creation of care management and population health management strategies for the long haul.
But the pace of preparation for risk is accelerating rapidly now, as both federal healthcare policy mandates and opportunities are pushing physicians and their medical groups forward. Not only has the Affordable Care Act (ACA) mandated participation in its value-based purchasing programs for both physicians and hospitals; it has required hospitals to reduce avoidable readmissions. And now, with the implementation of the MACRA (Medicare Access and CHIP Reauthorization Act) legislation, and the MIPS (Merit-based Payment System) that is a part of MACRA, looming next year, even more pressure is being put on physicians U.S. healthcare system-wide. What’s more, the federal Centers for Medicare & Medicaid Services (CMS) continues to push physicians and hospitals forward, with its expanding mandates for bundled payments, first for total-hip and total-knee replacement surgeries, and more recently for heart attack and CABG (coronary artery bypass graft) care, for both hospitals and physicians delivering care in hospitals.
Meanwhile, the evolution of the Medicare accountable care organization (ACO) programs is proceeding apace, with physician groups and hospitals moving forward not only in the Medicare Shared Savings Program (MSSP) for ACOs, but also the Pioneer ACO Program and the Next-Generation ACO Program. And, of course, hundreds of ACO contracts between private health plans and providers are evolving forward at the same time.
In fact, the medical group world’s pioneers have been busy moving forward into uncharted territory, says Don Crane, president and CEO of CAPG—“the voice of accountable physician groups”—a national association of medical groups involved in accountable care organization (ACO) development and other risk-based contracts. “Among the key learnings,” Crane says, “is that taking on higher levels of risk and moving to professional and not just institutional risk, is being seen as a good thing,” among the leaders of the most innovative medical groups in the U.S. “Doing so improves the quality of care, results in higher quality scores, and higher bonuses. And so moving up in risk is something that has grown in the CAPG membership,” he says.
Healthcare Informatics Editor-in-Chief Mark Hagland interviewed Crane this summer as part of his reporting for the magazine’s September/October cover story on physicians and risk. Below are excerpts from their interview.
How many of your association’s member groups are involved in the MSSP and Pioneer ACO programs right now?
There are three of our member groups in the Pioneer program, and in the MSSP, around 12 or 15.
And ACO development work harmonizes naturally with the kind of work you’re helping your member groups participate in overall, correct?
Yes, that’s right. We’re in the business of advocacy, of course, in Sacramento, California, and in Washington, D.C. We were very active in advocacy work on behalf of physician groups in the run-up to the ACA, and in MACRA now, and in Medicare Advantage, and in all the advanced alternative payment models, and also the ACO programs. And to be clear, we’re very deeply involved in both advocacy and education, around all the alternative payment models and programs. And as we move forward nationally and expand, our efforts are expanding. We’re putting on seminars, webinars, etc., partnering with other entities, to help teach how to deliver coordinated care. We probably had more of our members and sooner, fully wired with their electronic health records [EHRs], than anywhere else in the country.
Getting EHRs implemented early on was absolutely necessary to do the managing of care, the encounter data transmission, but also, coding and getting paid in a world where your patients are all risk-adjusted, and your revenue goes up or down based on their acuity. So we’ve had fully installed EMRs across almost all of our membership for a long time, and are doing a lot of data mining and risk stratification, and outreach, and predictive modeling, and disease registries. The measurement and management of data has been very key.