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.
According to McAneny, one critical key to practice transformation was creating clinical pathways for physicians and nurses and then implementing those pathways into a decision support tool.
During the session, the panelists discussed the operational challenges of entering alternative payment models as well as the challenges related to data governance and
Martin said Florida Hospital faced a challenge of having disparate data systems within its CIN as less than one-third of the physicians are employed physicians who utilize a common electronic health record (EHR). “That’s two-third of the physicians representing 130 different versions of EMRs and there’s a challenge of how to get that data to manage, coupled with some of the insurance companies and third-party administrators not willing to share data back with us so we could understand the wholeness of our population,” he said. To this end, Adventist Health invested resources in a population health services organization to build the infrastructure to manage these APMs methodologies, he said. “I think the ROI will be there as we build scale and investing in those resources up front is key to what, I believe, will be our success,” he said.
Martin stressed that it’s necessary for healthcare organizations to dedicate resources to alternative payment model initiatives. “It’s not part-time project, and it’s not the same skill set. It requires dedicated focus.”
Martin also cautioned that technology “is a tool not a panacea or a magic bullet.” “Technology enables you to identify patients,” he said, but successfully participating in alternative payment models also requires the right processes and people. He also noted that it’s vital to educate stakeholders throughout the process. “With stakeholders, such as physician sand office staff, you have to paint the picture and connect the dots to what you are looking to have measured and have managed and connect back to them why that’s good,” he said.
Discussing data issues and data quality, McAneny advised, “The best way to measure quality is to put a system on top [of your EHR]. The oncology best practices give you the ability to do pathway compliance and drill down to the individual patients to see whether they are compliant,” she said.
She also highlighted the need to have a technology tool that allows practices of all sizes to query their own data. “So, how do I solve problem x that is impacting my specialty, my practice… We need these other structures so we can transform healthcare into something where we can use these electronic tools to work more efficiently,” she said.
Casale says the work NewYork Quality Care has done with claims data has been very helpful for its ACO work. “It’s eye-opening for doctors to see all the places that patients go, so they understand the need to coordinate care. The claims data has been particularly helpful in engaging physicians around this population health and care coordination need,” he said.
He continued, “From a data perspective, marrying that claims data with pharmacy and lab and clinical data from the EMRs really is the magic sauce to be able to understand patient populations.”
When asked what recommendations on where healthcare organizations should start if looking to enter alternative payment models, McAneny said funding was a significant consideration. “It takes a fair amount of money to do transformation,” she said. “Find a payer who is interested in working with you. I’d like to see us switch to a franchise model. The National Cancer Care Alliance is 120 oncologists that banded together to purchase expensive data people and other functions to have the bandwidth to do what needs to be done. Have your franchise and your practice in your community that’s right-sized to fit you. How do you start transforming? You have to think it through, what works for the patients, to provide that infrastructure that’s needed and how are you going to fund it?”
Martin said, “When you look at funding any initiative like this treat it like a capital investment in a new market; you’re investing in infrastructure, in people, in developing care management programs and people associated with that with member experience.”
Healthcare organization leaders should also think about partnerships that already exist or that they can working on establishing, such as with post-acute care facilities, Casale said. “That’s going to be a critical factor in being successful. Go slow on risk. We are going very slow on risk. All the financial investment, you need to be prepared for the future; it is significant dollars to go into care management.”
Shared savings programs, either Medicare or commercial insurance plans, represent an opportunity to “go slow” on risk, Casale said. “Start with shared savings, upside only. It takes a while to change the culture and figure out bumps in the road.”
Martin added, “From risk standpoint, I wish we could swim slower, but change is happening very faster than you would expect. There’s a way to be smart about it.”