LUMINA Insights Blog

Recently, several clients who are working to improve value-based contracts have asked, “How do we better engage specialists in the reduction of total cost of care and improve access and outcomes for our members?” Nationally, the total cost of care increased 4.3 percent in 2016, and, according to CMS, is expected to increase at a rate of 5.5 percent from 2017 to 2026, leading to a steady increase in the percentage of healthcare spending compared to the gross national product.

This spending includes more than 30 percent hospital costs, 20 percent physician and clinical services, and 10 percent pharmaceuticals. Several studies that compare specialists with primary care physicians suggest that revenue generated within the surgical specialties far surpasses all the rest. Clearly, engaging specialists in developing and implementing reduction in total cost of care is imperative.

Nearly every aspect of the healthcare world is changing―constantly, unpredictably, and quickly. As stakeholders navigate their various paths, knowing what to expect can help with decision making about compliance, risk, cost, and more. We have identified 7 areas that healthcare leaders must navigate to stay ahead of change and remain agile, effective, and profitable.

Hospitals, health systems, and physician practices must find ways to adapt to the quickly changing market forces around them. Sources of change include value-based contracting, provider competition, consumerism, changes in government and commercial payment models, health system regionalization, government regulation, and technological innovation.

Health systems and physicians increasingly are finding it in their best interests to affiliate with one another in new ways, but how they collaborate depends on specific forces in their market. Some markets have larger populations and more significant provider competition than others. Some are more likely to have health plans that want to implement value-based payment models.

Through the continued journey of transitioning to a high-value, person-centric care model from a high-volume, process-centric care model, providers are forced to view care delivery through a new lens. As organizations consider digitization of their service offerings, having an effective analytics framework that produces actionable insights becomes imperative.

The need for actionable information continues to be a key strategic and operational gap for leaders of most healthcare organizations, and it presents challenges as they transition into value-based care. Provider organizations, particularly large, complicated health systems, have incredible amounts of data spread across disparate systems that do not easily communicate with one another.

Healthcare industry veterans Daniel Marino and Lucy Zielinski have co-founded Lumina Health Partners, a Chicago-based consulting firm that offers business advisory and leadership solutions to healthcare organizations.

The firm’s experienced team of consultants works hand-in-hand with clients to develop transformative results for the most difficult value-based strategy, digital innovation and analytics, clinical transformation, and leadership and governance challenges. Using a “lead to support” approach, the firm’s consultants create and activate strategies and plans that enable medical groups, hospitals, and health systems to realize measurable strategic, financial, clinical, and operational goals.

The Centers for Medicare & Medicaid Services (CMS) published its Medicare Shared Savings Program (MSSP) final rule in December 2018, and the final rule overhauls the MSSP and takes a new approach to transitioning providers to performance-based risk arrangements under accountable care models. A National Association of ACOs survey released in May 2018 indicated that 71 percent of the 82 ACOs that had been participating in Track 1 since 2012 or 2013 were likely to drop out of the MSSP before 2019, when they would be forced to enter a two-sided risk model (Track 1+, 2, or 3).

The U.S. healthcare system is steadily transitioning from fee-for-service (FFS) reimbursement to fee-for-value (FFV) payment. This change has already started to affect medical practice revenue, and it will have an even bigger impact in the years ahead.

Unfortunately, most physicians and practice managers understand only part of the FFV equation. Under FFV, they know the quality data they report to payers will affect their reimbursement, but many do not understand exactly how payers use these data to adjust payment.

What is the missing piece of this equation? Patient risk scoring.

Most health system executives have referral leakage on their minds. They wonder why their patients seek care elsewhere, especially after they have spent millions of dollars to draw them to their facilities through ad campaigns, purchased high-end equipment, and invested in employed medical groups that lose money in operational isolation.

Perhaps we should reconsider our use of the term “referral leakage.” It implies that patients are somehow confined. Confinement is one of the top reasons the public largely rejected HMOs. In contrast, in acknowledgement of patient consumerism and demand for choice, emerging payment models are often based on “attribution.” Attributed PPO patients may vote with their feet, and they often self-refer. The concept of referral leakage implies entitlement—and having a sense of entitlement may be a part of the problem.

The implementation and use of clinically integrated networks (CIN) continues to be an essential strategy in the journey to value-based care. The healthcare delivery system continues to become more and more complex, with new technologies, ongoing changes in the competitive landscape with mergers, acquisitions, and partnerships, and challenging payer contracts that are heading to real risk-based contracts in multiple episodes and larger populations.

By now, almost all healthcare providers have been affected by the shift to value-based care and are either working with or are aware of HCC coding.

It is practically impossible to participate in Medicare and not be subject to the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Consumer Assessment of Health Providers and Systems (CAHPS), or other programs that adjust payment based on quality and cost.

With this change, it can be difficult to manage the clinical documentation and diagnosis coding that impacts the population risk-adjustment factors that improve financial opportunity.

Unfortunately, most physicians and practice managers understand only part of the fee-for-value (FFV) equation. While they know the quality data they report to payers under FFV will affect their reimbursement, many do not understand exactly how payers use this data to adjust payment.

What is the missing piece of the equation? Patient risk scoring.