With the U.S. healthcare system undergoing rapid, transformative change, one of the big unanswered questions is, what will happen to hospital-physician alignment over time? Many physicians, burdened by bureaucracy and practice management challenges, are fleeing into employment by hospitals or by large hospital-affiliated or hospital-owned physician groups, while others are entering into a variety of contractual relationships designed to keep them afloat in practice. In a sense, physician alignment is a sort of “wild card” in the emerging healthcare system. How will accountable care and value-based healthcare delivery and payment work—will physicians mostly participate in those arrangements simply as hospital and health system employees, or will they chart a different course, somewhere between the extreme autonomy they’ve had under discounted fee-for-service reimbursement, and straight hospital system employment? No one really knows for sure, and it appears that things could evolve forward distinctly in the diverse metropolitan and regional healthcare markets across the U.S.
Some of those issues were discussed in one of the articles in this year’s Healthcare Informatics Top Ten Tech Trends story package, in the third issue of this year, in the article “Markets and Medicine—Where Do Physicians Land, in the Emerging World of U.S. Healthcare?” And one of the industry leaders interviewed for that article was Tricia Nguyen, M.D., a senior executive at the Falls Church, Va.-based Inova Health System, and who came to Inova last year in order to help to lead and expand a clinically integrated network and joint-venture insurance company, that Inova had created with Aetna. “My title was CEO of Commonwealth Health Innovation Network,” she explains. “But as it turns out, I found within 30 days that we didn’t have much to scale, so I’ve been focused internally, and now lead our population health efforts under the title of senior vice president for population health.”
Tricia Nguyen, M.D.
Dr. Nguyen sees a host of challenges, as well as definite opportunities, in the near future, in terms of how to get physicians and hospital-based health systems on the same page, and aligned to partner for the emerging future of healthcare.
Speaking of the northern Virginia healthcare market in which the five-hospital Inova system has a significant market share, Nguyen says, “This market is in a bubble; 70 percent of the population is insured by some carrier, employer-sponsored generally,” she says. The system serves a very affluent population, with “double-income, double-degree families”; and Inova controls 60 to 70 percent market share in its area. Given that market dominance, she says, “For the system, there’s not a real pressure to change, but we saw a real opportunity in this joint venture with Aetna. Providers are still making a lot of money on the fee-for-service payment schedule, because so many of their patients are commercially covered, so they don’t have to deal with a lot of government products. Some family practice and internist physicians have a high percentage of Medicare, but many are no more than 50 percent Medicare. Many are 70 to nearly 100 percent commercial. So as far as fee for value, they’re worried about MIPS and MACRA, and they want help with that.”
The important revelation that’s emerging for her and her colleagues, Nguyen says, is the realization that physician alignment to date has been missing a key component. “The primary care physicians have essentially been doing value-based care for several years here, but only for the CareFirst population,” she says, referencing CareFirst, a regional BlueCross BlueShield company that offers a range of health plans across Maryland, the District of Columbia, and northern Virginia. “Have they changed practice patterns? A little bit, but not much.” And, importantly, she says, she and her colleagues are realizing that “Fuller value will come when we can identify the high-value specialists, those who are high-performing, low-cost, given the way they practice, and using them. That to me is the secret, and no one has that secret mastered quite yet. And that’s because the tools don’t really exist to help. I believe that ACOs are too focused on primary care, and that primary care has to bear the burden to drive down the costs of care, when in fact it’s going to take collaboration with the specialists. While care coordination is important for holistic health, to generate real savings, you’re going to have to drive down specialty care costs as well.”
Inova encompasses five acute-care facilities, and employs about 500 providers, about 120 of them primary care, the rest are specialists. Inside the broader umbrella of value-based contracting, Inova operates Signature Partners, an accountable care organization with about 34,00 lives, and with a clinically integrated network (CIN). Signature Partners has been in place for over three years. “This year, “Nguyen says, “we decided to split up into two ACOs; one is a high-performing Inova medical group; the other is the original ACO that we kept going. The 34,000 number encompasses both.
One of the challenges, Nguyen says, is that “The specialists are not yet thinking about value. But the primary care doctors have been on a semi-value journey. CareFirst has created a PCMH [patient-centered medical home] model and payment model for primary care, to keep them independent. They’ve been very successful in their model. They give PCPs a certain base, and it’s under Medicare rates. And if they deem you to be PCMH, they give you x bump in your fee schedule. Once you’ve met that, for the level of engagement and savings you generate, you get that dollar amount based on your engagement and quality, as a form of an additional increase in your fee schedule for the next year.”
One of the challenges, Nguyen notes, is around the geography of her organization’s service area. “CareFirst is a health plan. They’re in Maryland and cross over to northern Virginia. It’s interesting the relationship that CareFirst has with Anthem. There’s a Highway 123 in northern Virginia. And CareFirst does not cross 123, and neither does Anthem. The program that they’ve had in place since 2012, has created virtual pods with primary care physicians, where they aggregate them together and call them a pod, and have engagement leaders and care managers, and they’re incentivized to work with care managers from CareFirst. So the primary care physicians have essentially been doing value-based care for several years here, but only for the CareFirst population.” Thus, the moderate but still-modest change in practice patterns that has been elicited from that set of contractual relationships.
Is this an example of the proverbial “one foot in the boat, one foot on the shore” phenomenon that so many are witnessing in U.S. healthcare right now? “Yes, absolutely,” Nguyen says. The existence of so many different payment systems “has kind of forced the market to think this way. About 120 of our employed medical group has a large book of business with CareFirst, and so they act differently with those populations now. They treat them as though it’s a fee-for-service environment, but our own primary care practices within are also different. There was a practice we acquired about a year ago that’s probably the premier primary care group within CareFirst. They’re one of the most efficient; and I can say that because their operational incentive award amounts are very high, among the highest in CareFirst.”
Speaking of that specific group, Nguyen says, “When I look at their ACO performance per beneficiary spend, their target spend is on average about $7,500 at most; many could run $11,000 per member per year. The way they practice is just very different. They try to manage everything virtually, telephonically, etc. We’ve started to try to uncover and find areas of opportunity to spread across our medical group, but also across our CIN. Our CIN doctors don’t really have an incentive to change. We’ve been able to generate change within the group, but the MSSP has not generated savings, so I think they’re becoming a bit disillusioned.”
What is the secret of their success? “It’s really in identifying the high-value specialists, those who are high-performing, low-cost, given the way they practice, and using them. That to me is the secret, and no one has that secret mastered quite yet. And that’s because the tools don’t really exist to help. I believe that ACOs are too focused on primary care, and that primary care has to bear the burden to drive down the costs of care, when in fact it’s going to take collaboration with the specialists. While care coordination is important for holistic health, to generate real savings, you’re going to have to drive down specialty care costs as well. And we have about 100 cardiologists we employ; and in a population of 100,000, how many cardiologists do you need? I probably have 20 times the cardiologists I need; I’m just guessing about the precise proportion, but we have an oversupply.”
Given the complexity of that situation, what is the solution to the path into value? “The solution,” Nguyen says, “is that they’re going to have to start tiering their network—by physician and not by group. They’re stuck in contracting by group. CMS [the federal Centers for Medicare and Medicaid Services] and the private payers will have to get to the level of contracting at the individual specialist level. This is how contracts happen today—under the tax ID number; and the performance of the individual provider in a group gets mixed in with their peers. And so it’s impossible to get down to that level.”
So what can CMIOs, chief quality officers, and other health system leaders do, to promote change in this context? “They can engage in provider profiling at the MPI level,” Nguyen says firmly. “Health system CMIOs need to start thinking about hospital-based specialist performance data, and claims data, in a broader, more strategic context. Nobody’s done that yet. Everybody’s mired in the whole concept of integrating EHR [electronic health record] and claims data. But so far, integrating EHR and claims data has led only to more robust reporting on select measures, but it’s primary care-specific. There’s no integrated provider reporting across their EHR, practice management data and claims data, to understand specialty care.”
For example, Nguyen says, “Take a cardiologist who practices in the hospitals and also bills for services. There’s a set of activities they do in the inpatient space that could be integrated. For example, if a patient is admitted for an acute MI, does the cardiologist provide that care or does the cardiologist also bring other specialists in? If they’re in for an acute MI, they could manage the person’s condition with consultation with a hospitalist internist, with follow-up by a diabetologist, for example. But unless a person is in acute renal care, then they need acute care by a nephrologist. But that data that can measure and performance by that specialist is available in the hospital data; you can also see it in the claims data as well. But if you take the case of an orthopedic surgeon that does a procedure in the hospital, one surgeon could cost more than another based on the prosthetics and implants. But that data is wrapped into the DRG that the hospital gets paid, and the hospital gets dinged, not the physician. And so it’s not in the claims data.”
In other words, she says, “We need to think about whom we’re holding accountable for the cost of care. It’s a shared responsibility. You have to manage the referral network and guide members to the high-value specialist. There are some basic things they can do with chronic conditions; but they must collaborate with their specialist peers.”
Does Dr. Nguyen have any other advice for CMIOs and CIOs? “Yes,” she says. “Don’t over-invest in EHR data for ACO quality measures at this time; focus on claims data. Everyone dismisses claims data. Inova has over-invested in EHR data that hasn’t yet generated savings. Claims data will help generate savings. Measuring quality, EHR yes, but a lot can be done through claims, if they’d just use the G-codes. And ACOs today are the price-takers from the payers and plans; they really should be the price-makers. And say, it’s going to cost $300 PMPM [per member per month] and not say, I’m going to take a percentage of premium, because percentage of premium could be a very arbitrary number.”