Strategies to Support Value-Based Reimbursement During Uncertain Times

As we are all experiencing a new normal in our personal and professional lives during the COVID-19 pandemic, the ability to keep up with the ever-changing clinical and regulatory environment in healthcare has made even the most seasoned healthcare executive feel as if they were swimming against the current.

Providers and Accountable Care Organizations (ACOs) engaged in risk-bearing contracts with CMS and other private payers have rightly expressed significant concern over the ability to accurately predict and have an impact on potential shared savings and losses. A recent National Association of ACOs (NAACOS) survey indicated over 56% of ACOs would consider exiting the program if CMS did not offer amenable solutions to protect against downside losses.

What Can Risk-Bearing Providers and ACOs Do?

As we saw last week, CMS is adjusting the financial methodology, in order to support keeping ACOs in the program. The ability to pivot and deploy resources to manage membership, as well as be proactive and adaptable in your overall strategic plan, is critical for any ACO or provider group taking risk. A key to supporting value-based financial goals is quickly activating strategies to engage members and continue to drive and deliver on clinical goals.

Providers and ACOs should consider:

  • Developing member registries or lists to assist in prioritizing outreach to members according to need. Work with health plan partners to tag team on those members falling into a coronavirus high-risk category, engage members with chronic care needs to ensure monitoring for potential crisis indicators, or in areas that are not as hard hit by the virus, target members for proactive preventative health screenings that can be done via remote patient monitoring.
  • Utilize non-traditional personnel to support outreach strategies. We understand it has been difficult to keep staffing levels at full capacity. Engage underutilized staff to support outreach efforts by developing simple decision trees they can follow with an escalation plan should they come upon a member needing urgent clinical support.
  • CMS has offered latitude in its guidance around telehealth. If your office has not yet offered telehealth services to members, this might prove to be the perfect opportunity to explore how telehealth solutions and remote patient monitoring could enhance your practice in the transition from volume to value. More people are looking beyond the standard urgent care visit to have greater flexibility in receiving care, especially follow up visits, remotely.
  • As you and your team work through the member registries, it affords the perfect opportunity to look at patients through a social determinants of health (SDOH) lens and develop strategies for areas such as medication access and food security, which are putting them at risk for failing to execute on a care plan. When you are at risk for the total cost of care of your patient panel, enabling the member to be as successful as possible by including community services in their plan of care can be a critical element of improving health.
  • The pandemic has opened conversations on mental health issues to a broader audience. Identifying and addressing potential mental health issues as part of the outreach process is an important proactive measure for the overall health of your patients.

Conclusion

GHG has the depth of experience from working with numerous health plans and providers to assist you in focusing on and developing strategies, such as those discussed above, that will keep your practice or ACO ahead of the fast-paced regulatory landscape. It is critical to be adaptable to challenges with patient care, as well as on the lookout for potential financial opportunities, such as risk adjustment and payor contract analysis, to assist in mitigating losses.

Please reach out to Ellie Martin to further discuss how our team can support your ACO or practice during this complex and challenging time.

Elena Martin
Elena Martin

Elena Martin Senior Director, Provider Strategies 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. Elena brings GHG clients more than 20 years of experience as a healthcare executive with a strong focus in all aspects of project management, sales, contracts and provider network development. In addition, she has extensive experience in hospital and physician contracting, governance and implementation, marketing, customer service training programs and human resources. Elena has worked for and held management positions for leading emergency medicine management companies and commercial, Medicare, and Medicaid health plans.

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