Health Care Is Saddling Providers With More Risk. Can You Bear the Load?

The GOP recently released a draft of their much-anticipated health care reform bill. Met by the public and lawmakers with mixed reviews, it’s likely that the bill will undergo significant changes before a modified version of it is passed. It’s introduction, however, represents a larger truth about American health care: that the system is ever-evolving. As a provider, you may be wondering how these myriad changes will affect your practice, and what fail-safes you should implement now to weather healthcare’s ebbs and flows.
The good news for providers is that an industry-wide investment of $1.6 trillion strongly indicates that value-based care is here to stay. So, physicians should continue to focus on improving patient outcomes and will continue to be rewarded based on the quality of care they provide to their patients.
Providers will also be expected to bear more risk in the coming years. With payers shifting to capitation, the proliferation of bundled payment models, and the consolidation of hospitals, post-acute facilities, and skilled nursing facilities, independent providers may begin to feel a financial squeeze.
Test the Waters
Don’t be overwhelmed by this industry-wide shift to payer consolidation and provider risk. There is bipartisan support for physicians to participate in merit-based incentive programs; it’s just best to enter them slowly. During the initial years, focus on your quality of care and getting used to submitting basic quality measures. Get comfortable with the cost of managing your patient population. Keep them out of expensive areas of the healthcare system by comanaging with preferred specialists; it’s important to think about all the interactions that patients have, not just those that occur within your office. For providers who own practices in ACOs, take advantage of Track 1+, a program that allows you to enter the Medicare Shared Savings Program on “training wheels,” and limits the amount of risk you bear. For providers in the MIPS program, get used to submitting basic quality measures and analyzing your QRUR (Quality & Resource Use) reports. Gear your efforts towards keeping your patients’ procedural utilization down, by aligning to evidenced-based medicine protocols and treatment options.
These simpler pathways give small provider groups an easier way to signal to the government that you’re ready to take on more risk. The goal is for providers to feel increasingly comfortable with assuming financial risk in exchange for larger incentives, with the eventual goal of reaching full-risk deals. The industry’s ultimate goal is to move providers into the advanced alternative payment (AAPM’s) tracks, where providers whose patient population exceed 25% in financial risk deals and thus responsible for the total cost of patient care.
Put Patients First
Buttressing this increase in provider risk is a healthcare system that grows more consumer-centric every day. Today’s patients are savvy consumers who demand price transparency. Higher insurance deductibles mean that in many cases, patients feel more like payers than patients: the average patient out-of-pocket procedure cost is $4,200-$4,500. In response to these patient shifts, providers need to become more accessible. Consider getting in front of your patients in more creative ways: co-manage with specialists who provide curbside consults, provide virtual visits, and encourage your patients and have them adopt tools to improve their self-management of chronic diseases. Implementing a consumer-oriented strategy early will allow your patient population to improve their collective health and feel more in-control of their healthcare.
Four Key Areas of Focus to Manage Financial Risk
A provider should be thinking about these four key areas as they manage their patient populations:

1. Healthcare Economics – Do you have the savvy to move into contracts and partner with risk-bearing entities? Do you know enough about risk adjustment, hierarchical condition, categorical coding, medical cost modeling, predictive modeling, and risk stratification to thrive in a value-based care environment?
2. Delivery System Architecture and Management – Co-managing with specialists is key. Do your patients have access to weight loss programs, nutritionists, and/or psychiatrists to help manage their outcomes?  Who are your care continuum partners, what data do you share, and how do they engage your patients to align with evidenced-based medicine protocols?
3. Managed Care Strategy – Which providers in your group might be ready to take on more risk? How can you increase the overall quality of care and performance in your practice? Risk readiness can be assessed in five areas of your practice which include: patient safety, clinical care efficiency, point-of-care population health delivery, patient-centered care, provider communication and care coordination.
4. Technology and Operations – Implement a system that assists with patient engagement strategies. Use clinical workflows that maximize patient time with physicians and help optimize the patient conversation. Your system should allow you to spend more time with patients by removing other burdens.

Interested in learning more about how to thrive in an environment geared toward more provider risk? Check out the second episode of The Break Room, in which we interview Scott Disch on expectations for healthcare in 2017.