The first question providers typically ask when talking about a value-based reimbursement arrangement is, “How much risk is involved?”
It’s an absolutely essential question. On its own, however, it fails to acknowledge the worthiest reason for moving to risk-based agreements: increased positive patient outcomes. As with so many things exposed by the coronavirus pandemic, this fact became abundantly clear at IKP Family Medicine earlier this year.
IKP is a 10-provider practice in northwest Houston that has participated in various risk-based reimbursement models since opening its doors in 2005. Some of our revenue currently comes from capitated contracts. So, when COVID-19 lockdowns pushed routine in-person visits to telehealth, our providers were able to quickly adapt to whatever workflows made the most sense for each patient—without worrying about “per service” reimbursement rules. For some patients, that meant conducting video visits. For others, plain old-fashioned phone calls delivered a more satisfying care experience.
For us, the pandemic has reinforced the idea that value-based care is as much about flexibility as it is about risk. Having a dependable revenue stream regardless of service volume offers the freedom to care for patients in whatever mode and manner is most appropriate to each circumstance.
While this flexibility concept isn’t exactly new, the events of recent months have shown why it’s important. Realistically, there are just some things for which nobody can prepare. Yet taking on risk lets providers more easily flex with the times, so they can focus on caring for their patients when they’re needed the most.
Take gradual steps
A recent survey of more than 500 C-suite healthcare executives shows that most organizations have been slow to pursue value-based arrangements. Only about 65 percent of survey respondents said they had 20 percent or less of their actual revenue at risk in 2018. However, the same survey also notes that 85 percent of respondents anticipate having some revenue in a full financial-risk model within the next few years.
This gradual upward trend is encouraging for a couple of reasons. First is the increasing acceptance of value-based care models among providers. Second—and equally important—is providers’ healthy regard for the strategic and operational transformation that these models represent.
Although the benefits of risk-based agreements can be substantial, that’s not to say they are easy to obtain. On the contrary, shifting to risk-based models requires practices to adopt a whole new approach to patient care—including overcoming the “provider vs. payer” mindset that has dominated healthcare for so long.
Over the last 15 years or so, IKP has experienced a slow and steady evolution in its risk arrangements. As a relatively small group practice, we have always had limits on the staff resources available to evaluate potential risk models and develop appropriate risk agreements. We have overcome that limitation, in part, through the support of a community of peers and the assistance of Cigna subsidiary CareAllies, which provides management services and support, including support for value-based arrangements, for physician groups.
If we’ve learned one thing about value-based care, it’s that success is dependent on effective collaboration and data sharing across all facets of healthcare. Provider, payer and patient data are all necessary to improve clinical and financial outcomes. Thus, the old “us vs. them” mentality must be abolished. Providers and payers alike must be willing to share information and insights to improve quality metrics, including data about:
● Health coverage
● Provider availability of care
● Population health quality metrics
● Health outcomes
● Utilization
● Social determinants of health
Getting buy-in to this new collaboration from physicians and clinical staff can be facilitated by having a physician executive directly involved in defining and reviewing the data elements contracted with the payer. This ensures that physician leadership is appropriately aligned, and that the goals of both the payer and the practice are harmonized.
Elevate staff workflows
IKP began incorporating risk into the practice by focusing on preventing avoidable utilization and improving patient engagement. This required the creation of a truly interdisciplinary team of physicians and nurse practitioners (NPs) working alongside registered nurses (RNs), pharmacists, licensed practical nurses (LPNs), social workers and others.
To achieve the desired patient-care goals, the practice now uses a three-pronged approach:
• Trained physician extenders concentrate their efforts on seeing all patients for physicals during the first quarter of the year. This serves two objectives. The first is to establish all necessary metrics for the year. The second is to provide a comprehensive service. Patients appreciate that the hour-long visit feels like a full physical exam—something they may not receive from other providers.
• Care coordinators and others leverage near real-time reports to examine gaps in care. In conjunction with this information, providers schedule follow-up visits with patients to ensure any disparities are identified and addressed.
• If and when challenges with social determinants of health are uncovered, we can close those gaps with the help of case management programs and in-home vendors. In some cases, we will even send one of our internal medical providers to care for patients in their homes.
This three-point strategy allows our care coordinators to synchronize plans to improve metrics and outcomes. They are responsible for pulling together various gaps-in-care reports and other information mined from health plan data. To fulfill this responsibility, they also must have the ability to collect appropriate practice data to support payer contracts. Consequently, IKP offers dedicated space for them to conduct chart reviews and audits. Once all relevant information is compiled, they then distribute the intelligence via chart alerts or emails to those who need it.
It has been noted already that data sharing is crucial to the ultimate success of a risk-based contract. Nonetheless, practices must be on guard against collecting and sharing data just for data’s sake. These efforts are only worthwhile if they result in stronger provider/patient relationships.
That is why our care coordinators view data collaboration as no more—and no less—than a tool that helps them work more closely with patients. Because of their ongoing relationships with both patients and providers, they can serve as indispensable intermediaries. When the data indicates that complex care management is desirable, they can expedite the appropriate services through the health plan or by arranging case management.
Improve quality & outcomes
The collaborative and data-driven workflows adopted by IKP demonstrate how practices can mitigate risk to enhance patient outcomes. To that end, IKP has:
• Met 100 percent of its quality measures.
• Enjoyed six percent patient panel growth since 2016, based on Cigna MA attribution between 2016 and 2020.
• Earned a 5-Star rating for 2021, based on preliminary 2019 Cigna Medicare data for Part C and Part D.
At their core, risk-based arrangements give providers the flexibility to care for patients in whatever manner allows them to achieve better outcomes. Although the risk inherent in a risk-based contract is real, questions about risk should not be the only ones asked when assessing value-based arrangements. Practices must understand the potential value such contracts may offer through their flexible approach to patient care.
Transformations in workflows, data exchange and collaboration across the healthcare continuum are essential to success. Yet when managed effectively, risk-based agreements create numerous avenues to help practices and their patients thrive. They put the emphasis back on quality care—which we all can agree is the right way to practice medicine.
Tim Irvine, M.D., is a physician at IKP Family Medicine and board member at Renaissance Physicians IPA
