Taking on two-sided risk is, well, inherently risky. As discussed by a range of industry experts, observers, and leaders in the May/June cover story, “Finding the Upside in Downside Risk,” for medical groups, hospitals, and health systems to dig into downside risk takes both strategic and tactical strengths and advantages. In that cover story, we quoted Adam Solomon, M.D., chief medical officer (CMO) of the Long Beach, Calif.-based MemorialCare Medical Foundation, as noting that, “Outside of the contract, the most important element to consider is your network. Who will you include? The basis is your primary care physicians. If you don’t select primary care physicians who naturally manage patients well—who utilize properly and don’t refer excessively—you won’t be successful,” Dr. Solomon told a conference audience in San Diego this spring. “Physicians won’t alter their care, so thinking about that is essential.”
As noted in that cover story, What the industry pioneers are finding, fundamentally, is that strategic vision, very strong provider network-building, cultural change, and continuous clinical and operational performance, facilitated by and driven by the leveraging of data and analytics, are all absolute critical success factors.
And all those interviewed for the May/June cover story agreed that a long path ahead faces providers, going forward in the risk-based world.
Among those interviewed for the cover story was Tomi Ogundimu, practice manager, research, at The Advisory Board Company in Washington, D.C. Ogundimu has spent numerous years advising providers on these issues. Excerpts from Editor-in-Chief Mark Hagland’s interview with her follow below.
What have been some of the some of the biggest learnings so far, overall, among providers taking on two-sided risk?
In terms of why some providers have jumped into two-sided risk—a lot of providers ask when the tipping point is. There’s a tension here, in that a lot of providers feel that their markets have not moved as quickly as they might have thought, into two-sided risk. A pretty significant amount of revenue is now being tied into value-based arrangements, but it remains diffuse among tens of thousands of contracts. The organizations are deciding that one of their primary growth engines will be becoming first-advantage movers in aligning some of their initiatives to move further upstream in care delivery, reworking primary care models, and also extending longitudinal self-care management through digital tools, etc., to the end result of demand destruction through moving interventions upstream..
What have been the biggest challenges in moving into downside risk?
Doing a good job at downside risk requires a lot of alignment across the continuum that might not be apparent in upside-risk arrangements. There is a lot of change management that has to take place in aligning care models from inpatient to outpatient,” she adds. “One clear example is in creating an enterprise-wide care management model that takes siloed care and case management from the hospital, and discharge planning and transition services, together with longitudinal patient self-management support and everything we do around post-acute care, to create a single, unified structure. At the end of the day, downside risk means we need to take a much more principled approach to our structures. And it’s really hard to take those legacy systems and create a unified care model where they’re truly managing the patients across the continuum, and quite frankly, extending that model out into the community where patients are.
Have hospital-based organizations too cautious in taking on risk? Physician organizations seem to be moving faster, correct?
Yes, physician-driven organizations are moving faster, because they can. Without having to support the structure of the hospital, they have an inherent flexibility. And they’re not destroying their own downstream demand by creating upstream interventions. Patients/consumers want more personalized care and they want more convenience, and in solving those two things, they don’t have the challenge of having to fill beds at the back end; they have that flexibility.
Physician group leaders have been laying out the landscape for physicians in practice, and giving them tools for the journey, correct?
Physician groups laying out the landscape for physicians in practice, giving them tools, yes?
Yes, and honestly, that isn’t anything new. As one example, even ten years ago, Blue Cross Blue Shield of Michigan was doing this. Physicians inherently want to do the right thing. They’re also data-driven, so if you show them their data and give them real-world data, and explain why they should be changing their patterns, that’s extremely important. And per IT, how can we make things easier for them? And what can we do to take away administrative steps and allow them to spend more time practicing medicine?
What are the smartest groups doing around data?
That’s a large question! For one, they’re only sharing data back to physicians that is well-validated from the physicians’ perspective; it’s risk-adjusted, taking into account the severity of patient panels; and it’s actionable data. It’s not just focused on outcome measures, but also on process measure, to make sure they’re affecting things in the long-run; and they’re patient-oriented. So, tracking and making sure we’re adhering to these measures—that’s very important.
How quickly will things tip in the next few years?
It’s hard to give a national-level answer to that question, because a lot of this will be very market-specific. And a lot of push coming from CMS is still connected with voluntary programs. And in some of those same markets, the private payers are ready to hand some downside risk to progressive providers ready to take it on. And I would also look at the Medicaid managed care markets, where some providers are willing to take on risk, and where those markets will move faster than others. In certain markets, providers are looking to do a better job of care delivery model transformation. And per your question about the chicken or the egg, really smart providers are first investing in resources where they can invest in new models.
What kinds of resources will be needed going forward?
IT capabilities will be needed, whether digital health investment or telehealth capabilities. I would look at care management. New Mexico, for example, and other states focused on Medicaid managed care—they’re finding the value of community health workers.
Community health workers, including promotoras, are making a real difference in some communities.
Yes. And a lot of providers have legacy community health worker programs that they may have built for just one segment of their population years ago, and are looking now to recreate those programs now, not just, for example, in Latino communities, but across low-income zip codes. And models like that, scale.
What should CIOs, CMIOs, and other senior healthcare IT leaders, be doing, right now?
I would expand thinking in the health information technology space. So often, we were so focused on integrating disparate EHRs [electronic health records] across the system; now, with so many focused on the social determinants of health, how to take different pieces of information we can collect, now that we can leverage machine learning and AI and create patient profiles and really understand what risk is involved, through the EHR, through claims data, but even beyond EHR and claims data, we’ll be looking beyond those areas, into social determinants of health data and consumer-facing data.
Is there anything you’d like to add?
I’m excited for where we’re going in healthcare. We’ve been doing a lot of research recently around the social determinants of health data, and we’re reaching an ‘aha’ moment around providers taking on downside risk; typically, advanced providers are looking to impact utilization through housing programs, food insecurity, transportation, and behavioral health issues. And the truly progressive organizations are looking to create transformation in their local markets, by addressing the gaps between poverty and wealth. And SDOH work is how providers are caring out a role in addressing poverty in communities; so the most progressive are involved in areas that will involve a five-to-ten-year investment, through address poverty.
