One of the Ten Transformative Trends presented to the readers of Healthcare Innovation by the publication’s editors in the March/April issue was “The Plunge Into Risk: A New Calculus for Physicians and Hospitals.” That article looked at the range of complexities facing the multispecialty physician groups, hospitals, and integrated health systems taking on two-sided risk in risk-based contracting. As referenced at the outset of the article, “One trend that has become marked in the past few years, but that perhaps remains underappreciated, is this: that independent multispecialty physician groups are moving ahead of hospital-based health systems in taking on two-sided risk. It is not so much that the fact of that trend in itself is shattering or even surprising; but some of the implications involved are significant.”
As mentioned in the article, the publication’s State of the Industry Survey, whose results were published in the January/February issue, found that, “With regard to value based contracts, survey respondents reported the following: 35 percent were involved in the Medicare Shared Savings Program (MSSP), 22 percent were involved in the Next Generation ACO (accountable care organization) program, 27 percent were involved in a Medicaid ACO; and 42 percent were involved in an ACO with one or more private health insurers. Still, only 4 percent of respondents reported that more than 20 percent of their overall reimbursement involved two-sided risk. Meanwhile, 4 percent said that 15 to 20 percent involved two-sided risk; 18 percent said that 10 to 15 percent of their reimbursement involved two-sided risk; 12 percent said that 5 to 10 percent involved two-sided risk; and 22 percent said that 0 to 5 percent of their reimbursement involved two-sided risk.”
Among those interviewed for the Trend on two-sided risk were two leaders at the Alexandria, Virginia-based American Medical Group Association (AMGA): Darryl Drevna, senior director, regulatory affairs; and Jamie Miller, senior director, government relations. AMGA leaders have been at the forefront of the push to help lead provider organizations into risk-based contracting. Indeed, AMGA member medical groups have been among the most successful in their risk-based contracts, among all patient care organizations nationwide. Drevna and Miller addressed both risk-based contracting in general, as well as the potential for legislative and regulatory changes in this calendar year. Below are excerpts from Editor-in-Chief Mark Hagland’s February interview with the two AMGA senior executives.
What does the landscape around risk-based contracting look like to you, in terms of the kinds of calculations that provider leaders are engaging in right now, around two-sided risk?
Darryl Drevna: Whether you’re a multispecialty group practice, a large integrated system, or anywhere in between, you’re looking for a couple of things before moving into risk. First, do you have the population to support it? How many covered lives do we have? The other thing is stability in the framework around the regulations that manage these programs. Per the MSSP [Medicare Shared Savings Program], there’s been a whole lot of shifting in terms of what’s expected, under Pathways to Care. In this latest round of rulemaking, they made fairly significant changes to how providers have to report on quality. And those are major for providers, because they have to dig in and figure out whatever they need to change care delivery models, workflows, staffing; you can’t turn these ships around in mid-ocean. Sometimes, I think there’s a lack of understanding of the challenges. So providers need a consistent set of rules around all this.
Jamie Miller: As you’re probably aware, under the MACRA program [based on the Medicare Access and CHIP Reauthorization Act of 2015] obviously incentivized taking on risk; as it stands right now, the incentive payments will end in 2023 or 2024—the 5-percent bonus is over in a few years. We’ve testified to Congress that the incentive program has to last longer. If you’re in MIPS [the Merit-based Incentive Payment System], you’re at 0.25 percent in potential adjustment [for success with risk], but the fee schedule changes; in APMs [alternative payment models], you get a 0.75 fee adjustment. We’re pushing for that change. When things cost money, obviously, we have to go to Congress.
So the way MACRA works, you have to reach a certain APM revenue threshold in order to get the Part B bonus. Starting in this performance year of 2021, you’d have to hit 75 percent of your revenue to get the 5-percent bonus, but we were able to get them to keep it at 50 percent.
Drevna: Jamie is talking about the qualification standards to be considered in an advanced alternative payment model. You can’t have 2 percent of patients in the model. You’ve got to have a threshold of payment or patients to get into the model. It had been 75 percent of revenues; that was very unrealistic as a threshold. So based on conversations with Jamie, they were able to get a change in the law. It’s still not an easy thing to do, but 50 percent is more reasonable.
What do you think might happen in Congress later this year, in terms of the reimbursement policy landscape? And, if you could have your wishes, what would you wish for?
Miller: I would say, obviously, that our organizations are still having trouble with canceled elective surgeries, so their financial situations are difficult, to say the least; so, it would be great to see more money in the provider relief fund or more assistance. And the idea that telehealth is here to stay—our patients want it. So we would like to know for sure that the [loosening of the payment restrictions around telehealth] would be made permanent, including around the originating site of care, geographic restrictions, audio-only visits, etc.
Do you think that those provisions might actually be made permanent?
Miller: In the HEALS Act [the Health, Economic Assistance, Liability Protection and Schools Act, introduced into the U.S. Senate in July 2020] that [Senator Mitch] McConnell introduced [on July 27, 2020, when Sen. McConnell (R-Ky.) was Senate Majority Leader], his response to the HEROES Act [the Health and Economic Recovery Omnibus Emergency Solutions Act, introduced into the U.S. House of Representatives on May 12, 2020, by Rep. Nita Lowey (R-N.Y.)], there was a telehealth utilization study request of HHS [the U.S. Department of Health and Human Services].
Drevna: Yes, MedPAC [the Medicare Payment Advisory Commission] is looking at how to modernize telehealth under the law—getting the geographic restrictions waived, etc. MedPAC’s looking at that; it’s on their agenda.
Miller: And that discussion between committees in the House and Senate… it’s around utilization. And one of the biggest problems with getting this provision permanentized is that right now, all these provisions last until the end of the public health of the emergency. Medicare said these things will last until the end of 2021. So Congress is receptive, but they do have time. The deadline will be the end of 2021. We’re going to keep pushing.
Drevna: I think we’ve been so focused, and I don’t expect it to change, on pandemic response and recovery; and that will continue to be the focus above anything else, and I don’t see this ending anytime soon. So part of it has to be a robust vaccine distribution plan. And you’ve seen sort of the fits and starts. So to help address that problem, number one, there’s the supply issue. But as the supply ramps up, if you look at the President’s plan for responding to the pandemic, relying a lot on community vaccination centers and FEMA and the National Guard, and grocery stores, etc., we think that locally based multispecialty physician group practices are ideal locuses. Patients trust us, and we have the infrastructure.