Helping Smaller Providers Assess Their Ability to Take on Risk

We often note that when a team works well together, it can collectively accomplish more than its members alone. Your network providers, especially the individual and small groups, have been inundated with information from all directions on how to prepare for a shift to value-based payment models. This shift can seem overwhelming to a small practice without the resources to effectively manage the changes needed to be successful under a new model. 

Here are some things to consider when talking to providers about their ability to take on risk and navigate the new reimbursement model.

A significant portion of the information that providers receive on where they rank compared to their peers on quality metrics comes from benchmarks established by the health plans with whom they are contracted. It is also understood that providers have been wary of the data they have received. For providers, working together to provide real-time and transparent data has been at the top of the wishlist when building trust and long-term partnerships. It is also one of the first items plans and providers can work on together.

In turn, the verbiage of “taking on risk” can have a multitude of meanings for a provider. Working together to determine a collective definition and true ability for a practice to manage upside/downside or full risk is also an area in which plans can support their smaller provider groups.  

As health plans, we have focused on designing incentive plans or risk-sharing arrangements to promote compliance with regulatory requirements, stars, or risk adjustment goals. However, we may not have fully attended to what our providers, especially our smaller providers, have the ability to handle. Our larger system partners have the edge, but with so many providers fighting to stay independent, it is worth taking the time to support their needs as well.

To remain provider-centric, it is imperative that we understand where our smaller providers are – not only in their ability to take on risk and make the shift from fee-for-service to value-based reimbursement – but also in their overall infrastructure. 

During various projects, we have shadowed highly skilled provider relations representatives as they travel in the field to meet with office managers and providers. We have often found plans to have incorrect office addresses and practices to have a lack of staffing – making it difficult for the office to have time to digest the information we are sending, or for the data to get into the hands of the correct person and find a way to effectively integrate via technology to ensure a more effective means of communication for our smaller partners. 

Another observation to note is that while your representative is there with the best of intentions to review provider data and offer suggestions on how to improve and capture bonus dollars left on the table, they are one of many reps sitting in the office vying for a minute to talk with the office staff. It is a juggling act for the provider to be able to provide top-notch clinical care for his or her patients while also meeting the demands of a new value-based world.

In order to ensure your largest asset is prepared, why not empower your network with a checklist on how to evaluate their practices? We have provided a 15-point checklist that providers can utilize to examine the skills, knowledge, systems, and questions they should ask themselves when evaluating their ability to navigate the new reimbursement landscape. Once providers feel more empowered, blending a true engagement architecture can begin.

Checklist: Key Questions for Providers to Discuss Prior to Entering a Risk-Based Contract

  1. What is our experience in accepting risk? 
    • If there is a history of accepting risk, how has it worked out? 
    • What were the challenges? 
  2. How do we define Risk? 
    • Upside only
    • Upside/Downside
    • FFS plus performance-based bonus (P4P)
    • Capitation
    • Episode of care payments (bundled payments)
    • Percentage of premium
    • Full risk
    • Other
  3. What is our income/loss distributions formula?
  4. Will we share risk equally?
  5. What will the total investment for the organization, both in monetary and human resources, be to transition to value-based reimbursement?
  6. Do we have the patient volume, per payer, to make the investment worthwhile? And are we sure our patient attribution is correct? 
  7. Does this shift fit with our overall strategic plan? 
  8. Have we done the predictive modeling needed and how accurate are our projected savings? 
  9. Do we have the data capture, aggregation, analysis, and reporting tools to monitor clinical utilization and medical spend? 
  10. Do the savings include the total cost, i.e. training, new software, maintenance, potential changes in liability insurance? 
  11. How will the shared savings be distributed among the providers and what will we reinvest in infrastructure? 
  12. Do we have the ability and time to evaluate our patterns of care, hospitalizations, readmits and high cost expenditures to determine where we can reduce waste? If not, can we outsource? 
  13. Do we have a physician champion, leadership, and governance to implement and drive the process? 
  14. Are their stakeholders outside of the organization that are critical to the success and if so, do we have a strong alliance or partnership in place? This would include all providers across care settings that would affect your episode of care and thus the reimbursement. 
  15. If taking downside risk, what is the best way to prepare the organization if any money is owed? For example: reinsurance, funds in escrow, line of credit.

GHG is poised to assist your plan in developing a fully engaged provider engagement architecture to ensure the cross-functional needs of all your department “asks” come to the provider at the right time for shared success.

For additional questions and inquiries about how GHG can support your needs, please contact me at emartin@gormanhealthgroup.com

Elena Martin
Elena Martin

Elena Martin is Senior Director of Provider Strategies at Gorman Health Group (GHG). In this role, she has acted as Project Manager for numerous network expansion projects on a national level and has been a key consultant in Accountable Care Organization (ACO) and End-Stage Renal Disease Seamless Care Organizations (ESCO) application and development.

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