In a rapidly changing healthcare landscape, payers are asking providers to shift from volume-based care, or fee-for-service, to a value-based reimbursement model and, faced with the challenge of improving care quality but lowering cost, many healthcare organization are considering implementing an alternative payment model or developing an action plan to do so. Yet, the move from fee-for-service to value-based payment models significantly impacts business operations.
During a pre-conference session at HIMSS17 Sunday as part of the Business of Healthcare and New Payment Models track, industry stakeholders representing three distinct segments—a prominent health system, a large physician provider group and a solo practitioner physician group—shared their insights about implementing alternative payment models (APMS) and risk-sharing in a value-based world. The panelists discussed the impact of changing payment models on their organization’s business operations and the strategies they are employing in response to these challenges.
The recommendation of all three panelists for organizations considering alternative payment models was to “go slow” as they detailed the operational and data governance challenges they have encountered in their practice transformation journeys.
Mark Martin, president, Florida Hospital Physician Network and vice president of development, Florida Division of Adventist Health System, said, “We use the term “swim to risk”—don’t just jump in, you’ve got to build the infrastructure and build a process to make sure you’re able to manage it.”
Adventist Health System, which operates 43 hospitals in nine states with 80,000 employees and serves just short of 5 million patients annually, is involved in a number of APMs, according to Martin. He said, “When we talk about alternative payment model methodologies or arrangements, it is risk, by definition; it’s a changing payment methodology, but somebody is getting risk shifted to it. Start with looking at shared savings opportunities, as opposed to shared risk or full risk.” He continued, “As a hospital system, we’ve had full risk for every uninsured patient, we have full risk for them, so we built care management around our community care effort. By looking at the uninsured and “frequent flyers” in the ED, it’s a great opportunity to build infrastructure and show value to the community and to the hospital from an economic perspective.”
The health system’s bundled payment initiatives include participation in the Bundled Payments for Care Improvement (BPCI) initiative and, additionally, 16 Adventist Health System hospitals are in the designated regions and will be participating in the Comprehensive Care for Joint Replacement (CJR) program. The Centers for Medicare & Medicaid Services (CMS) selected 67 U.S. geographic regions for the five-year pilot CJR program. Beginning last April, nearly 800 hospitals nationwide must participate in the CJR program, the first U.S. mandatory shared-risk, outcomes-based payment model, and the first initiative to make hospitals financially responsible for patient care, including recovery.
Further, Adventist Health participates in the Medicare Shared Savings Program Accountable Care Organization (MSSP ACO) program in the North Carolina market, the Comprehensive Primary Care Plus program, a national advanced primary care medical home model, in the Kansas marketplace and, in central Florida, some Adventist Health hospitals participate in the Medicare Advantage program. Florida Hospital also developed a clinically integrated network (CIN), which is a partnership between Florida Hospital and its employed and independent physicians. In January 2016, the health system entered into a shared risk arrangement managing 20,000 lives.
“We are in our infancy in many, if not most, areas, “Martin said. ‘As a faith-based organization, our mission fits to the part of looking at the chronically uninsured through our community care program. From a mission perspective, it’s a no brainer for us. We’ve seen wonderful results by partnering and focusing on care management for the indigent and the uninsured to reduce visits, reduce cost and improve health. It’s a good way of transitioning in this area of APMs,” Martin said.
Other members of the panel included Paul Casale, M.D., a cardiologist and executive director of NewYork Quality Care, the ACO of New York-Presbyterian, Weill Cornell Medicine and Columbia University College of Physicians and Surgeons, and Barbara McAneny, M.D., a medical oncologist/hematologist from Albuquerque, N.M. In 2012, McAneny received a $19.8 million award from the Centers for Medicare & Medicaid Innovation (CMMI) to test how oncology private practices could provide cancer patients better care at a lower cost. This award, called COME HOME (for Community Oncology Medical Home), later helped form Medicare's Oncology Care Model. McAneny formed Innovative Oncology Business Solutions Inc., a company now assisting physician practices in developing the process changes needed for The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). McAneny also is a member of the American Medical Association Board of Trustees.
McAneny described the practice transformation required to shift from fee-for-service to value-based payment and care as “changing the tires while you’re driving 65 miles an hour down the freeway.” As a physician in private practice, McAneny says she continues to see 25 to 30 patients a day. “The first challenge for your practice to transform is that you can’t stop doing the patient care while you’re doing the transformation. If you aren’t seeing patients, you are not generating income and there’s no money to do practice transformation,” she said.
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