On today's episode, join us as we dive into the world of Value Based trends in primary care markets with guests Mike Scribner, John Crew, and Kelly Mooney. They share their expertise and discuss how independent PCPs will be impacted by these trends in healthcare. They will highlight both Commercial and Medicare arrangements in the marketplace, how practices are impacted by such, as well as how best to thrive and incorporate into an overall managed care strategy.
Transcript
Credits
Production & Editing: Nyla Wiebe
Show Notes & Transcription: Aaron C Higgins
Social Media Management: Jeremy Miller
Executive Producers: Mike Scribner & John Crew
Visit our website
Like us on Facebook
Tweet @ us on Twitter
Follow on Linkedin
Send an email contact@shpllc.com
Production © Strategic Healthcare Partners, LLC.
All rights reserved.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Aaron Higgins (00:08):
Welcome to Beyond the Stethoscope Vital
Conversations with SHP.
While we're on our breakpreparing for the next season,
we're revisiting some of ourmost insightful episodes to keep
you informed.
In this replay all the way backfrom Season 2, we dive into the
evolving landscape ofvalue-based care in the primary
care market with industryexperts and SHP founders Mike
(00:29):
Scribner and John Crew.
We're also joined byvalue-based care expert Kelly
Mooney.
In this episode, our expertsbreak down the latest trends
that are shaping the future ofprimary care, exploring how
independent practices are beingimpacted by commercial and
Medicare arrangements.
Independent practices are beingimpacted by commercial and
Medicare arrangements.
They discuss the challenges andopportunities that these
(00:50):
changes bring and sharestrategies that can help
practices not just survive butto thrive with an overall
managed care framework.
So, whether you're a providernavigating the complexities of
value-based care or simplycurious about the future of
healthcare, this episode ispacked with insights that remain
as relevant today as they werewhen we first aired it.
Stay tuned while we revisitthis vital conversation to help
(01:10):
you stay ahead of the curve.
Mike Scribner (01:18):
So, as an opening question, you guys let's talk
about what trends in value-basedcare you've seen, kind of start
high level and kind of tell mewhat value-based trends you see
are out there and whatopportunities you think that
primary care in particular maybe encountering.
John Crew (01:35):
Well, I'll jump in.
This is John Prude, I think,and Kelly can certainly add to
this, I think.
When you think about trends, Ithink you really talk about the
sort of the evolution ofvalue-based care in general in
other states.
Historically speaking, when wehave value-based care, they tend
(01:56):
to gravitate into the largermetropolitan areas, because it's
all about attribution,everything's about attribution.
So they're looking at what's myfastest way to get a
significant number of patients,and so if you can go into an
Atlanta or an Augusta orSavannah where you can pick up
20,000 attributed lives withfour or five groups, that sort
(02:19):
of becomes your target market.
And so the consequence of thatis is that particularly rural
providers, who don't have thatkind of volume, they tend to get
left out.
It's not just that they're leftout, they're just those
opportunities don't exist forthem.
And so what we do here at SHP iswe're trying our best to figure
out how to incorporate thosepractices and give them
(02:43):
opportunities that otherwisethey wouldn't have, and part of
that is by being able tocoalesce them together where
their combined attributionbecomes the same meaningful
attribution as a couple of largepractices in the metropolitan
areas, and I think that therearen't a lot of people out there
doing that, and I think that'swhat makes us a little bit
(03:03):
unique at SHP out there doingthat, and I think that's what
makes us a little bit unique atSHP.
Have you thought about how tocoalesce and work collectively
with the rural providers?
Part of that build is going totake place because there's going
to be a bit of a blueprintthat's going to come from
Medicaid.
As Medicaid moves intovalue-based care, they're going
to have to bring value-basedcare into the rural markets.
(03:23):
So we may have part of thatblueprint moving forward that
we'll be able to go back andshare with the other payers in
the marketplace.
Mike Scribner (03:34):
Describe to us the types of models that have
evolved in the market from aMedicare Advantage perspective
have kind of come first, but Iguess commercial came first and
now Medicare Advantage is kindof coming into the market.
Give us some description of themost prevalent two or three,
four models that are out there.
Kelly Mooney (03:53):
So the most common model, I would say that has the
largest footprint from aMedicare Advantage standpoint,
is going to be Humana's modelpractice engagement.
The key component of thatcontinues to be quality driven
Primary care practices, probablyvery familiar with HEDIS
quality metrics A1Cs that arebeing done.
(04:15):
Are you closing your care gapsfor screenings, for colonoscopy,
breast cancer screenings, allof those different studies and
tying quality and financialincentives to meeting those
metrics for your population,keeping them out of the
emergency room?
The other component that we'veseen tie in more to that is,
(04:39):
upside shared savings models.
Shared savings models.
Now, the challenge on that sidehas been particularly in rural
areas.
To John's point, aggregatingenough of a footprint to move
any financial metrics continuesto be a challenge and with
smaller populations of providerswithin communities it becomes
(05:01):
more difficult to redirect carein those settings.
Mike Scribner (05:05):
I guess, medicare aside, what's the most
prevalent commercial model outthere and how does it differ?
Kelly Mooney (05:11):
The only real model that's out there today is
Anthem's enhanced personalhealth care model and it is tied
to again an attribution modelbased on who is delivering the
most primary care to aparticular patient, similar
(05:31):
HEDIS metrics keeping people outof the emergency room, doing
your transitional care,management, monitoring
medications for your patientsand there's also a financial
component that has been evenmore challenging to hit than the
Medicare Advantage side hasbeen.
Mike Scribner (05:51):
Before we start talking about sort of
operational issues with beingsuccessful in those programs,
which is where I want to hit.
How does a typical primary carepractice get involved in one of
those programs in the firstplace?
How are they accessed in thefirst place?
John Crew (06:09):
They're recruited.
I mean, if you really go backto the inception of Value Base,
it really was the original MSSPplans and so everybody recruited
primary care into that.
And unfortunately, becauseCMS's original model has evolved
dramatically which is the goodpart unfortunately because in
(06:31):
the early stages a lot of thoseMSSPs failed and so it was only
after CMS sort of adjusted andKelly talked more to this, but
it's only after they adjusteddid physicians become to be
successful.
But at the end of the day theywere recruited.
And I will go back again torepeat Kelly, they're recruited
based on their attributionthey're looking at.
(06:53):
Originally, you know, in theMSSPs they needed 5,000 lives
and over the course of timethey've discovered that the
higher the attribution, the lessrisk there is for losing money.
So now most people went to 10and 15 and now really a top
number is 20,000.
That's sort of what people arelooking for.
And so even though the red,white and blue population is
(07:17):
declining and there's more andmore of it, that's going into
the MA plans and that's what'sbringing more of the MA life,
there's still opportunity withinthe traditional red, white and
blue.
But because they have to berecruited, I'm going to go back
to what I said in the beginning.
It's been to this point.
(07:37):
It has been our organization,shp, which has brought those
lives up into partnering withACOs, whether it be the red,
white, blue or the MAs, and wedo have at least one red, white,
blue ACO that we brought thevendor in and we put them
together with the physicians.
That has been incrediblysuccessful.
(07:57):
And then on the commercial side, I know Kelly mentioned that
the Blues DPHC program was themost prevalent, then Humanis
program.
I think they all have somemodel but unfortunately, at
least to this date on thecommercial side, I don't know
that they have been at leastwith our client bases.
They have been incrediblysuccessful is because I think
(08:25):
and I would really like to hearKelly comment on this I think
part of that is the payers arebeing forced to implement
standardized models that may beuniversal across state to state
and they're very claims-baseddriven versus clinically driven,
and so I think that's had a bitof a negative impact.
That's why the MSSP has beensuccessful, because you get
real-time data or close toreal-time data.
(08:47):
That's actionable.
Kelly, you have any thoughts?
Kelly Mooney (08:51):
Yeah, that's a great point, John.
The challenge to accessible andactionable data is the biggest
hurdle in any of thenon-traditional Medicare models.
Obviously, there's always adelay because claims filing is
going to run behind for allhealth care providers, but
(09:38):
there's been a real difficultyfor all of the payer partners
that we've worked with themarket and there are limitations
to what you can do about theirdownstream contracts, how
material the financial returnscan be.
Mike Scribner (09:47):
Is this worth the squeeze in terms of whatever
operational changes we're goingto talk about?
John Crew (09:53):
It can vary.
I think there's a risk reward.
I think the reward that we aremost familiar with has been what
our clients have done, and wehave clients that have done
incredibly well in it.
Financially it has meant asignificant amount to their
practices and that's throughaccumulation of an MSSP on the
(10:14):
commercial side the EPHC thatKelly spoke about.
You know their relationshipswith other payers, including
Medicaid.
All of those combined they havebeen very successful.
Their practice flows within thepractice but for the most part,
(10:41):
I think they would tell youthat they are still practicing
medicine the way they alwayspractice medicine.
I think what they would tellyou that has been the real
benefit to them is theyunderstand coding better.
They understand the coding toacuity better.
They understand the impact ofnot doing that, not doing that,
I think they understand, ofclosing gaps, of really managing
your bottom 5%, which isdriving about 80% of your costs.
(11:01):
I think they would tell youthat, but I don't think that.
I think what they would alsotell you is that their imaginary
thought of what that was goingto be, the requirements as far
as staffing changes, all ofthose things.
I think they would tell youthat it wasn't as severe as they
thought it was going to be.
But the real challenge in thistoo, michael, is that I think we
(11:22):
have to recognize that what Iwas saying earlier about these
value-based models haven't beenavailable in the rural
communities.
And as these companies continueto come into Georgia now you're
getting some saturation out ofAtlanta, a little bit of
saturation out of the other MSAs, and so you're really getting
down to the rural market,becomes a little, can become a
(11:44):
little bit of a target market,particularly, say, for a boy
crossing their EPHC, things likethis.
But what is happening iseverybody.
There's two factors.
Happening is everybody.
There's two factors.
One is everybody is pushing togo at risk because the risk is
where the greatest reward is forthe money.
The more risk you take on thetraditional red, white and blue,
(12:05):
the better the opportunities.
If you take the full risk, youno longer have to split with cms
50 50.
You can split at 75 25.
There are different withinthere.
So there's a big push to dorisk.
And then on the MA side there'sa big push to get to capitation
and these things in and ofthemselves can be a little
frightening.
(12:25):
But the fact is these modelshave proven to be successful.
But to go from doing nothing tocapitation or from nothing to
be at a financial risk is, Ithink, has unintended
consequences and I think that'swhy, for our clients, we have
tried to work with them, tomatch them with the right
(12:47):
partners where they won't be atany kind of financial risk or
harm to their practice.
And value-based medicine is anopportunity to augment that
revenue but not to replacefee-for-service and I think you
have to have that mindset.
Mike Scribner (13:04):
So, again, keeping on kind of dropping this
down another level.
What are and I guess I'lldirect this at you, kelly what
are the sort of two, three, fouritems that have driven
practices to be successful ineither an ACO model or the
Medicare Advantage plans thatare prevalent in the market?
Kelly Mooney (13:25):
So I think the initial driver is physician
commitment to the model andsituating their practice for
success.
Part of that is working a carecoordination function within
their practices.
John, anything to add?
John Crew (13:44):
Yeah, I think that it really is models that have been
driven by the providersthemselves, as opposed to having
someone come in and tell themwhat to do.
I think the models have beensuccessful.
Their partners have provideddata and resources.
I think it's been on thephysicians themselves to
collaborate with each other andhold each other accountable.
(14:06):
And really I've been in somefascinating meetings with
physicians and I'm not aclinician, but I've been in some
fascinating physicians wherephysicians are talking to each
other about why you use one codeversus another code and what
that means, and why you use thismodifier versus this modifier,
because this is what it means interms of acuity or cost or all
(14:26):
of these things.
And I think the education thatwasn't insurmountable, but it
was an education.
And I think once folks learnedthat, they really began to
understand the importance ofreally making sure that and I
can't overstate this to makingsure that they were capturing
the right acuity and doing theright coding, and those things
(14:48):
in and of itself and, kelly, youcomment on this those things in
and of itself are probablyabout 80% of the lift.
Mike Scribner (14:55):
So explain that a little further for the regular
person in the audience here.
Why is coding so important thatit's tied to the financial
return?
How to connect those dots.
Kelly Mooney (15:07):
For particularly traditional Medicare and
Medicare Advantage, the fundingthat goes into the financial
model.
What they're going to base yourfinancial return off of, is
based on patient acuity, andthat's captured through
something we call riskadjustment.
That are the diagnosis codesthat are submitted on claims,
(15:32):
those reset annually.
So even for conditions thatwould never change say, one of
the highest risk adjusted codes,if you're HIV or AIDS positive,
that's going to drop off at thebeginning of every year, even
though in today's clinical worldthat condition will never
change.
So making sure that you'recapturing how sick and the
(15:54):
actual acuity of your patientsare every year means that the
plan is appropriately funded forthe care that that patient is
expected to receive.
And so that's the key componentyou can be much more impactful
on the funding than managingdownstream cost.
You will never lose backdollars that you didn't capture
(16:16):
by miscoding your patient,because their costs are going to
be the same.
You just weren't funded forthat care.
John Crew (16:22):
And as a lay person, Michael, what that means to me
is that if you don't capturethose codes, you're still
treating those codes, but you'reonly targeted for what you're
treating for that time to CMSthat looks like that you're out
of line with your care, thatyou're giving the cost for your
(16:43):
care Because while you'retreating that, you would have
been by not coding it and goingback and picking up all of those
things that follow.
I always think of heart attacks.
People have had heart attacks.
By not keeping those thingsgoing, it looks like your
patients are sick when they're,not when they're in actuality.
Mike Scribner (17:00):
All right.
So shifting down to OK, I seethe, I see the benefit, I see
the sort of the key drivers thathave driven success.
Talk about the con for just asecond.
What?
What operational concerns?
Practice throughput, disruption.
Have we seen kelly, you andjohn, have you all seen in
(17:21):
practices that have gone in thedeep end and adopted sort of a
full model along these lines?
John Crew (17:28):
hardest thing is there.
There are people that get it,and then there are people that
don't get it, that are willingto change.
There are people that arewilling to understand the
importance of coding and why Ineed to code that way and
they're willing to adopt it anddo it and move forward.
And then, unfortunately, thereare providers in these groups.
(17:48):
They got in just to see if theygot a check, for no other
reason.
They're not committed, they'rejust I want to get in just to
see if I get a check.
And so once your data startscoming out, it's going to tell
you I mean, it is absolutelygoing to tell you these are the
folks that are killing it anddoing the right thing and these
are the folks that aren't.
The first thing you're going todo is go to those that aren't
(18:09):
and you're going to try to bringthem up to the level that the
others that are.
I mean to the level that theothers that are.
I mean you're going to.
It's going to be peer-to-peerconversations about.
Here are the things you need todo to be successful, because if
you're not successful, you arenegatively impacting me, you're
affecting my money.
So the goal is to do that andat the end of the day.
(18:29):
If you have those that justabsolutely never buy in at the
end of the day, the downside isthey're going to kick them out.
Mike Scribner (18:37):
But at a throughput perspective and I
guess, kelly, this one's to youtoo.
What's the feedback that we'vebeen on a practice's ability to
not disrupt the regularthroughput of patients?
As, john, as you alluded tobefore, we're a fee-for-service
state, we're paid per click.
Is our experience thatimplementing effective care
(19:00):
coordination and and vbcsupportive activities in the
practice has it slowed down thepractice?
What are the sort of thedisruptive things that a
practice needs to be aware of asthey go through this?
I'm talking pretty low level,operationally.
Kelly Mooney (19:16):
I don't think that we've seen that level of
concern from the practices thathave integrated value-based care
models.
The biggest sort of disruptionthat we've seen is really on the
lower-level staff in thepractice in terms of identifying
and targeting in their own EMRwho's tied to what model, what
(19:40):
care gaps they need to close.
So that's where we've seen moreof the operational work done.
John Crew (19:47):
I will say and Kelly can add to this one of the
things, mike, that it'simportant when you're trying to
identify the right partnerassuming you don't want to do
this on your own when you'retrying to identify the right
partner, I think the mostcritical conversation and this
is indicative of whether it'sMedicare Advantage, medicaid,
commercial, any other it'sreally what resources is your
partner putting out there?
(20:07):
Are they boots on the ground?
Are they sending coders out?
Are they getting people in themarket out there with you to
help close those care gaps?
Are they making outbound callsto patients to get them in or
they helping verify that?
You know, if you're diabetic,you're supposed to have a,
(20:28):
supposed to have an eye exam andthey're not being dependent on
hoping the eye doctor sendsnotes back to the primary care.
They're out there tracking thatdown.
It's really what are they doingbecause, remember, most of
these partners are getting, youknow, at least half of these
savings.
So the tools that you need tobe successful that's the pot it
(20:50):
needs to come out of they needto reinvest in the market and
the more successful they are asa group, the more you want your
partner reinvesting in themarket and resources to help you
achieve those success, asopposed to it all being solely
dependent on your practice.
Mike Scribner (21:09):
John kind of concluding point to kind of wrap
this back up and get kind ofback to the high level.
What would our generalrecommendation be?
I'm a five doctor primary carepractice in Vidalia, georgia,
independent.
I really haven't stuck my toein the water of this at all.
What do I do next?
What do I do first?
John Crew (21:31):
I think we you know, for us, you know, if there are
clients, we're and this issomething they want to do that
the thing we want to do is wewant to try to identify the
right partners and we've gotsome working relationships.
You want to identify somepartners out there that you can
collaborate with to bring themin at a zero risk to the
(21:51):
practices.
And so what a lot of ACOs havestarted doing is they have
started building now multipleACOs started doing is they have
started building now multipleACOs, and so what they'll do is
they'll have one that they puteverybody in and it's sort of
the learning curve ACO, and it'swhere you learn how to interact
, get data, give data and howsuccessful you can be.
(22:12):
And then, if you're reallysuccessful, what they tend to do
is they gravitate you up to anACO that has been in existence
and has made really good money,so they see you as a contributor
that's going to enhance thatone, and so they move you up
into another ACO.
And for the others, theycontinue to try to train and
help and bring along, but at norisk.
(22:33):
But it's really sort of like youknow, it's sort of like getting
value-based care 101, you sortof it's sort of like getting
value-based care 101, but you'reat zero risk, you can't fail,
you just may not, can pass, andso the reality of it is is
that's sort of the models thatwe're trying to find out there
and look for Same thing on theMA side of it.
We want to find partners thatdon't require you to go directly
(22:54):
to capitation.
We want to find partners thatare going to work with you,
continue to work with you wherethere's upside dollars in this,
build the same models.
Having those tiered models is akey, because when you've got a
model that's incrediblysuccessful, then it's your goal
to try to get from the A tier tothe B tier, because the money's
already in the B?
tier.
You don't have to it's alreadythere.
(23:15):
You're just going to add to that.
So it's getting people thatwant to put those tiered models
in to help them come through.
And as you get into the uppermodels that are doing incredibly
well, you do want to go tocapitation.
You absolutely want to takerisks because you're going to
kill it.
You, you, you've been doing it,you're going to continue to do
it, but that learning curve youdon't want to be in any position
(23:37):
to take any risk at all.
Is that a fair statement, kelly?
Mike Scribner (23:45):
It is John.
Aaron Higgins (23:48):
Okay, well, thank you all for your time today.
Jason Crosby (23:54):
You've been listening to Beyond the
Stethoscope Vital Conversationswith SHP, a production of
Strategic Healthcare Partners.
For more information about ourpodcast, including back episodes
, show notes, transcripts andmore, visit our website at
shplccom slash podcasts.
Aaron Higgins (24:04):
And I know you've heard it before, but please
consider rating our podcast andyour favorite podcast out.
It helps make others aware ofthe show.
Jason Crosby (24:12):
And our podcast wouldn't be possible without our
wonderful team of folks.
Aaron Higgins (24:16):
Editing and production assistance by Nyla
Weave and myself, Aaron Higgins.
Jason Crosby (24:20):
And your episode hosts are Aaron Higgins and
myself, Jason Crosby.
Aaron Higgins (24:24):
Our social media coordinator is Jeremy Miller.
Jason Crosby (24:27):
Our executive producers are also our
principals Mike Scribner andJohn Crew.
Aaron Higgins (24:32):
For more from SHB , consider following us on
social media, including Facebook, twitter and LinkedIn.
Jason Crosby (24:38):
And, as always, thank you for listening and have
a great, wonderful day.
Welcome to Beyond the Stethoscope Vital
Conversations with SHP.
While we're on our breakpreparing for the next season,
we're revisiting some of ourmost insightful episodes to keep
you informed.
In this replay all the way backfrom Season 2, we dive into the
evolving landscape ofvalue-based care in the primary
care market with industryexperts and SHP founders Mike
(00:29):
Scribner and John Crew.
We're also joined byvalue-based care expert Kelly
Mooney.
In this episode, our expertsbreak down the latest trends
that are shaping the future ofprimary care, exploring how
independent practices are beingimpacted by commercial and
Medicare arrangements.
Independent practices are beingimpacted by commercial and
Medicare arrangements.
They discuss the challenges andopportunities that these
(00:50):
changes bring and sharestrategies that can help
practices not just survive butto thrive with an overall
managed care framework.
So, whether you're a providernavigating the complexities of
value-based care or simplycurious about the future of
healthcare, this episode ispacked with insights that remain
as relevant today as they werewhen we first aired it.
Stay tuned while we revisitthis vital conversation to help
(01:10):
you stay ahead of the curve.
Mike Scribner (01:18):
So, as an opening question, you guys let's talk
about what trends in value-basedcare you've seen, kind of start
high level and kind of tell mewhat value-based trends you see
are out there and whatopportunities you think that
primary care in particular maybe encountering.
John Crew (01:35):
Well, I'll jump in.
This is John Prude, I think,and Kelly can certainly add to
this, I think.
When you think about trends, Ithink you really talk about the
sort of the evolution ofvalue-based care in general in
other states.
Historically speaking, when wehave value-based care, they tend
(01:56):
to gravitate into the largermetropolitan areas, because it's
all about attribution,everything's about attribution.
So they're looking at what's myfastest way to get a
significant number of patients,and so if you can go into an
Atlanta or an Augusta orSavannah where you can pick up
20,000 attributed lives withfour or five groups, that sort
(02:19):
of becomes your target market.
And so the consequence of thatis is that particularly rural
providers, who don't have thatkind of volume, they tend to get
left out.
It's not just that they're leftout, they're just those
opportunities don't exist forthem.
And so what we do here at SHP iswe're trying our best to figure
out how to incorporate thosepractices and give them
(02:43):
opportunities that otherwisethey wouldn't have, and part of
that is by being able tocoalesce them together where
their combined attributionbecomes the same meaningful
attribution as a couple of largepractices in the metropolitan
areas, and I think that therearen't a lot of people out there
doing that, and I think that'swhat makes us a little bit
(03:03):
unique at SHP out there doingthat, and I think that's what
makes us a little bit unique atSHP.
Have you thought about how tocoalesce and work collectively
with the rural providers?
Part of that build is going totake place because there's going
to be a bit of a blueprintthat's going to come from
Medicaid.
As Medicaid moves intovalue-based care, they're going
to have to bring value-basedcare into the rural markets.
(03:23):
So we may have part of thatblueprint moving forward that
we'll be able to go back andshare with the other payers in
the marketplace.
Mike Scribner (03:34):
Describe to us the types of models that have
evolved in the market from aMedicare Advantage perspective
have kind of come first, but Iguess commercial came first and
now Medicare Advantage is kindof coming into the market.
Give us some description of themost prevalent two or three,
four models that are out there.
Kelly Mooney (03:53):
So the most common model, I would say that has the
largest footprint from aMedicare Advantage standpoint,
is going to be Humana's modelpractice engagement.
The key component of thatcontinues to be quality driven
Primary care practices, probablyvery familiar with HEDIS
quality metrics A1Cs that arebeing done.
(04:15):
Are you closing your care gapsfor screenings, for colonoscopy,
breast cancer screenings, allof those different studies and
tying quality and financialincentives to meeting those
metrics for your population,keeping them out of the
emergency room?
The other component that we'veseen tie in more to that is,
(04:39):
upside shared savings models.
Shared savings models.
Now, the challenge on that sidehas been particularly in rural
areas.
To John's point, aggregatingenough of a footprint to move
any financial metrics continuesto be a challenge and with
smaller populations of providerswithin communities it becomes
(05:01):
more difficult to redirect carein those settings.
Mike Scribner (05:05):
I guess, medicare aside, what's the most
prevalent commercial model outthere and how does it differ?
Kelly Mooney (05:11):
The only real model that's out there today is
Anthem's enhanced personalhealth care model and it is tied
to again an attribution modelbased on who is delivering the
most primary care to aparticular patient, similar
(05:31):
HEDIS metrics keeping people outof the emergency room, doing
your transitional care,management, monitoring
medications for your patientsand there's also a financial
component that has been evenmore challenging to hit than the
Medicare Advantage side hasbeen.
Mike Scribner (05:51):
Before we start talking about sort of
operational issues with beingsuccessful in those programs,
which is where I want to hit.
How does a typical primary carepractice get involved in one of
those programs in the firstplace?
How are they accessed in thefirst place?
John Crew (06:09):
They're recruited.
I mean, if you really go backto the inception of Value Base,
it really was the original MSSPplans and so everybody recruited
primary care into that.
And unfortunately, becauseCMS's original model has evolved
dramatically which is the goodpart unfortunately because in
(06:31):
the early stages a lot of thoseMSSPs failed and so it was only
after CMS sort of adjusted andKelly talked more to this, but
it's only after they adjusteddid physicians become to be
successful.
But at the end of the day theywere recruited.
And I will go back again torepeat Kelly, they're recruited
based on their attributionthey're looking at.
(06:53):
Originally, you know, in theMSSPs they needed 5,000 lives
and over the course of timethey've discovered that the
higher the attribution, the lessrisk there is for losing money.
So now most people went to 10and 15 and now really a top
number is 20,000.
That's sort of what people arelooking for.
And so even though the red,white and blue population is
(07:17):
declining and there's more andmore of it, that's going into
the MA plans and that's what'sbringing more of the MA life,
there's still opportunity withinthe traditional red, white and
blue.
But because they have to berecruited, I'm going to go back
to what I said in the beginning.
It's been to this point.
(07:37):
It has been our organization,shp, which has brought those
lives up into partnering withACOs, whether it be the red,
white, blue or the MAs, and wedo have at least one red, white,
blue ACO that we brought thevendor in and we put them
together with the physicians.
That has been incrediblysuccessful.
(07:57):
And then on the commercial side, I know Kelly mentioned that
the Blues DPHC program was themost prevalent, then Humanis
program.
I think they all have somemodel but unfortunately, at
least to this date on thecommercial side, I don't know
that they have been at leastwith our client bases.
They have been incrediblysuccessful is because I think
(08:25):
and I would really like to hearKelly comment on this I think
part of that is the payers arebeing forced to implement
standardized models that may beuniversal across state to state
and they're very claims-baseddriven versus clinically driven,
and so I think that's had a bitof a negative impact.
That's why the MSSP has beensuccessful, because you get
real-time data or close toreal-time data.
(08:47):
That's actionable.
Kelly, you have any thoughts?
Kelly Mooney (08:51):
Yeah, that's a great point, John.
The challenge to accessible andactionable data is the biggest
hurdle in any of thenon-traditional Medicare models.
Obviously, there's always adelay because claims filing is
going to run behind for allhealth care providers, but
(09:38):
there's been a real difficultyfor all of the payer partners
that we've worked with themarket and there are limitations
to what you can do about theirdownstream contracts, how
material the financial returnscan be.
Mike Scribner (09:47):
Is this worth the squeeze in terms of whatever
operational changes we're goingto talk about?
John Crew (09:53):
It can vary.
I think there's a risk reward.
I think the reward that we aremost familiar with has been what
our clients have done, and wehave clients that have done
incredibly well in it.
Financially it has meant asignificant amount to their
practices and that's throughaccumulation of an MSSP on the
(10:14):
commercial side the EPHC thatKelly spoke about.
You know their relationshipswith other payers, including
Medicaid.
All of those combined they havebeen very successful.
Their practice flows within thepractice but for the most part,
(10:41):
I think they would tell youthat they are still practicing
medicine the way they alwayspractice medicine.
I think what they would tellyou that has been the real
benefit to them is theyunderstand coding better.
They understand the coding toacuity better.
They understand the impact ofnot doing that, not doing that,
I think they understand, ofclosing gaps, of really managing
your bottom 5%, which isdriving about 80% of your costs.
(11:01):
I think they would tell youthat, but I don't think that.
I think what they would alsotell you is that their imaginary
thought of what that was goingto be, the requirements as far
as staffing changes, all ofthose things.
I think they would tell youthat it wasn't as severe as they
thought it was going to be.
But the real challenge in thistoo, michael, is that I think we
(11:22):
have to recognize that what Iwas saying earlier about these
value-based models haven't beenavailable in the rural
communities.
And as these companies continueto come into Georgia now you're
getting some saturation out ofAtlanta, a little bit of
saturation out of the other MSAs, and so you're really getting
down to the rural market,becomes a little, can become a
(11:44):
little bit of a target market,particularly, say, for a boy
crossing their EPHC, things likethis.
But what is happening iseverybody.
There's two factors.
Happening is everybody.
There's two factors.
One is everybody is pushing togo at risk because the risk is
where the greatest reward is forthe money.
The more risk you take on thetraditional red, white and blue,
(12:05):
the better the opportunities.
If you take the full risk, youno longer have to split with cms
50 50.
You can split at 75 25.
There are different withinthere.
So there's a big push to dorisk.
And then on the MA side there'sa big push to get to capitation
and these things in and ofthemselves can be a little
frightening.
(12:25):
But the fact is these modelshave proven to be successful.
But to go from doing nothing tocapitation or from nothing to
be at a financial risk is, Ithink, has unintended
consequences and I think that'swhy, for our clients, we have
tried to work with them, tomatch them with the right
(12:47):
partners where they won't be atany kind of financial risk or
harm to their practice.
And value-based medicine is anopportunity to augment that
revenue but not to replacefee-for-service and I think you
have to have that mindset.
Mike Scribner (13:04):
So, again, keeping on kind of dropping this
down another level.
What are and I guess I'lldirect this at you, kelly what
are the sort of two, three, fouritems that have driven
practices to be successful ineither an ACO model or the
Medicare Advantage plans thatare prevalent in the market?
Kelly Mooney (13:25):
So I think the initial driver is physician
commitment to the model andsituating their practice for
success.
Part of that is working a carecoordination function within
their practices.
John, anything to add?
John Crew (13:44):
Yeah, I think that it really is models that have been
driven by the providersthemselves, as opposed to having
someone come in and tell themwhat to do.
I think the models have beensuccessful.
Their partners have provideddata and resources.
I think it's been on thephysicians themselves to
collaborate with each other andhold each other accountable.
(14:06):
And really I've been in somefascinating meetings with
physicians and I'm not aclinician, but I've been in some
fascinating physicians wherephysicians are talking to each
other about why you use one codeversus another code and what
that means, and why you use thismodifier versus this modifier,
because this is what it means interms of acuity or cost or all
(14:26):
of these things.
And I think the education thatwasn't insurmountable, but it
was an education.
And I think once folks learnedthat, they really began to
understand the importance ofreally making sure that and I
can't overstate this to makingsure that they were capturing
the right acuity and doing theright coding, and those things
(14:48):
in and of itself and, kelly, youcomment on this those things in
and of itself are probablyabout 80% of the lift.
Mike Scribner (14:55):
So explain that a little further for the regular
person in the audience here.
Why is coding so important thatit's tied to the financial
return?
How to connect those dots.
Kelly Mooney (15:07):
For particularly traditional Medicare and
Medicare Advantage, the fundingthat goes into the financial
model.
What they're going to base yourfinancial return off of, is
based on patient acuity, andthat's captured through
something we call riskadjustment.
That are the diagnosis codesthat are submitted on claims,
(15:32):
those reset annually.
So even for conditions thatwould never change say, one of
the highest risk adjusted codes,if you're HIV or AIDS positive,
that's going to drop off at thebeginning of every year, even
though in today's clinical worldthat condition will never
change.
So making sure that you'recapturing how sick and the
(15:54):
actual acuity of your patientsare every year means that the
plan is appropriately funded forthe care that that patient is
expected to receive.
And so that's the key componentyou can be much more impactful
on the funding than managingdownstream cost.
You will never lose backdollars that you didn't capture
(16:16):
by miscoding your patient,because their costs are going to
be the same.
You just weren't funded forthat care.
John Crew (16:22):
And as a lay person, Michael, what that means to me
is that if you don't capturethose codes, you're still
treating those codes, but you'reonly targeted for what you're
treating for that time to CMSthat looks like that you're out
of line with your care, thatyou're giving the cost for your
(16:43):
care Because while you'retreating that, you would have
been by not coding it and goingback and picking up all of those
things that follow.
I always think of heart attacks.
People have had heart attacks.
By not keeping those thingsgoing, it looks like your
patients are sick when they're,not when they're in actuality.
Mike Scribner (17:00):
All right.
So shifting down to OK, I seethe, I see the benefit, I see
the sort of the key drivers thathave driven success.
Talk about the con for just asecond.
What?
What operational concerns?
Practice throughput, disruption.
Have we seen kelly, you andjohn, have you all seen in
(17:21):
practices that have gone in thedeep end and adopted sort of a
full model along these lines?
John Crew (17:28):
hardest thing is there.
There are people that get it,and then there are people that
don't get it, that are willingto change.
There are people that arewilling to understand the
importance of coding and why Ineed to code that way and
they're willing to adopt it anddo it and move forward.
And then, unfortunately, thereare providers in these groups.
(17:48):
They got in just to see if theygot a check, for no other
reason.
They're not committed, they'rejust I want to get in just to
see if I get a check.
And so once your data startscoming out, it's going to tell
you I mean, it is absolutelygoing to tell you these are the
folks that are killing it anddoing the right thing and these
are the folks that aren't.
The first thing you're going todo is go to those that aren't
(18:09):
and you're going to try to bringthem up to the level that the
others that are.
I mean to the level that theothers that are.
I mean you're going to.
It's going to be peer-to-peerconversations about.
Here are the things you need todo to be successful, because if
you're not successful, you arenegatively impacting me, you're
affecting my money.
So the goal is to do that andat the end of the day.
(18:29):
If you have those that justabsolutely never buy in at the
end of the day, the downside isthey're going to kick them out.
Mike Scribner (18:37):
But at a throughput perspective and I
guess, kelly, this one's to youtoo.
What's the feedback that we'vebeen on a practice's ability to
not disrupt the regularthroughput of patients?
As, john, as you alluded tobefore, we're a fee-for-service
state, we're paid per click.
Is our experience thatimplementing effective care
(19:00):
coordination and and vbcsupportive activities in the
practice has it slowed down thepractice?
What are the sort of thedisruptive things that a
practice needs to be aware of asthey go through this?
I'm talking pretty low level,operationally.
Kelly Mooney (19:16):
I don't think that we've seen that level of
concern from the practices thathave integrated value-based care
models.
The biggest sort of disruptionthat we've seen is really on the
lower-level staff in thepractice in terms of identifying
and targeting in their own EMRwho's tied to what model, what
(19:40):
care gaps they need to close.
So that's where we've seen moreof the operational work done.
John Crew (19:47):
I will say and Kelly can add to this one of the
things, mike, that it'simportant when you're trying to
identify the right partnerassuming you don't want to do
this on your own when you'retrying to identify the right
partner, I think the mostcritical conversation and this
is indicative of whether it'sMedicare Advantage, medicaid,
commercial, any other it'sreally what resources is your
partner putting out there?
(20:07):
Are they boots on the ground?
Are they sending coders out?
Are they getting people in themarket out there with you to
help close those care gaps?
Are they making outbound callsto patients to get them in or
they helping verify that?
You know, if you're diabetic,you're supposed to have a,
(20:28):
supposed to have an eye exam andthey're not being dependent on
hoping the eye doctor sendsnotes back to the primary care.
They're out there tracking thatdown.
It's really what are they doingbecause, remember, most of
these partners are getting, youknow, at least half of these
savings.
So the tools that you need tobe successful that's the pot it
(20:50):
needs to come out of they needto reinvest in the market and
the more successful they are asa group, the more you want your
partner reinvesting in themarket and resources to help you
achieve those success, asopposed to it all being solely
dependent on your practice.
Mike Scribner (21:09):
John kind of concluding point to kind of wrap
this back up and get kind ofback to the high level.
What would our generalrecommendation be?
I'm a five doctor primary carepractice in Vidalia, georgia,
independent.
I really haven't stuck my toein the water of this at all.
What do I do next?
What do I do first?
John Crew (21:31):
I think we you know, for us, you know, if there are
clients, we're and this issomething they want to do that
the thing we want to do is wewant to try to identify the
right partners and we've gotsome working relationships.
You want to identify somepartners out there that you can
collaborate with to bring themin at a zero risk to the
(21:51):
practices.
And so what a lot of ACOs havestarted doing is they have
started building now multipleACOs started doing is they have
started building now multipleACOs, and so what they'll do is
they'll have one that they puteverybody in and it's sort of
the learning curve ACO, and it'swhere you learn how to interact
, get data, give data and howsuccessful you can be.
(22:12):
And then, if you're reallysuccessful, what they tend to do
is they gravitate you up to anACO that has been in existence
and has made really good money,so they see you as a contributor
that's going to enhance thatone, and so they move you up
into another ACO.
And for the others, theycontinue to try to train and
help and bring along, but at norisk.
(22:33):
But it's really sort of like youknow, it's sort of like getting
value-based care 101, you sortof it's sort of like getting
value-based care 101, but you'reat zero risk, you can't fail,
you just may not, can pass, andso the reality of it is is
that's sort of the models thatwe're trying to find out there
and look for Same thing on theMA side of it.
We want to find partners thatdon't require you to go directly
(22:54):
to capitation.
We want to find partners thatare going to work with you,
continue to work with you wherethere's upside dollars in this,
build the same models.
Having those tiered models is akey, because when you've got a
model that's incrediblysuccessful, then it's your goal
to try to get from the A tier tothe B tier, because the money's
already in the B?
tier.
You don't have to it's alreadythere.
(23:15):
You're just going to add to that.
So it's getting people thatwant to put those tiered models
in to help them come through.
And as you get into the uppermodels that are doing incredibly
well, you do want to go tocapitation.
You absolutely want to takerisks because you're going to
kill it.
You, you, you've been doing it,you're going to continue to do
it, but that learning curve youdon't want to be in any position
(23:37):
to take any risk at all.
Is that a fair statement, kelly?
Mike Scribner (23:45):
It is John.
Aaron Higgins (23:48):
Okay, well, thank you all for your time today.
Jason Crosby (23:54):
You've been listening to Beyond the
Stethoscope Vital Conversationswith SHP, a production of
Strategic Healthcare Partners.
For more information about ourpodcast, including back episodes
, show notes, transcripts andmore, visit our website at
shplccom slash podcasts.
Aaron Higgins (24:04):
And I know you've heard it before, but please
consider rating our podcast andyour favorite podcast out.
It helps make others aware ofthe show.
Jason Crosby (24:12):
And our podcast wouldn't be possible without our
wonderful team of folks.
Aaron Higgins (24:16):
Editing and production assistance by Nyla
Weave and myself, Aaron Higgins.
Jason Crosby (24:20):
And your episode hosts are Aaron Higgins and
myself, Jason Crosby.
Aaron Higgins (24:24):
Our social media coordinator is Jeremy Miller.
Jason Crosby (24:27):
Our executive producers are also our
principals Mike Scribner andJohn Crew.
Aaron Higgins (24:32):
For more from SHB , consider following us on
social media, including Facebook, twitter and LinkedIn.
Jason Crosby (24:38):
And, as always, thank you for listening and have
a great, wonderful day.
Popular Podcasts
24/7 News: The Latest
The latest news in 4 minutes updated every hour, every day.
Stuff You Should Know
If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations. Follow now to get the latest episodes of Dateline NBC completely free, or subscribe to Dateline Premium for ad-free listening and exclusive bonus content: DatelinePremium.com