Adjusting to Value-Based Care as an Independent Practice

With growing pressure for independent practices to team up for accountable care and looming value-based reimbursement, many practices nationwide are uncertain of how to move ahead toward success for their practice and their patients.

At the Medical Group Management Association's (MGMA's) 2015 Annual Conference, this will be the focus of one session, co-presented by Stephen Cavalieri, chief medical officer for Richmond, Va.-based inHEALTH, a provider of population health management services, and Gerard Filicko, inHEALTH’s group's senior vice president of clinical services.  inHEALTH provides services for MD Value Care, a multispecialty physician organization in Central Virginia composed of more than 450 physicians from 23 independent practices.

"At the end of the day, [value-based care] is coming,” Filicko recently told Physicians Practice. "This is the new environment that physicians have to be prepared for, regardless of what you think of the government or Obamacare …."

Filicko and Cavalieri recently provided a preview of their session and insight into their experiences at MD Value Care for Physicians Practice.

Physicians Practice: Why is population health so important to small medical practices? Why should it be?

Gerard Filicko:  We have physician groups still operating under this idea that fee-for-service medicine is going to be around for a long time and I don't think that's the case. I think the way the industry is moving, the way the carriers are moving, the way federal and state governments are moving, we are seeing more and more value-based purchasing, more and more demand for demonstrating that the dollars that are spent in healthcare are being spent wisely. 

We've worked here in Virginia with a group of 400 physicians for a number of years and have established some success, I think, in what an independent physician model could look like. We just wanted to be able to share some of those experiences with folks who are just now beginning to test the waters in value-based care.

Stephen Cavalieri, MD: Earlier this year, HHS announced the goals of tying 30 percent of Medicare payments to alternative payment models by the end of 2016 and 50 percent by the end of 2018. This is not going to be just for health systems.  That's going to be for all physicians, tying quality measures to physician practices, hospital systems, skilled nursing facilities, home health agencies, [etc.]. The entire continuum of care is going to be increasingly measured by, and paid for, on how they can deliver in a value-based environment.  The effect will be to de-silo American healthcare.

It isn't the patients you are seeing in your practice, it's the patients you are not seeing.  Therefore, it's about the care transitions, the gaps in care, and the patient issues about which until now practices haven't known.  So in a population health environment, systems need to be developed to track and close these gaps.  One simple example is if you are diabetic and you haven't seen your physician in a year for your hemoglobin A1C levels or lipid panel, there is clear evidence that your risk of being hospitalized increases significantly. Until recently, physicians didn't have tools or workflows to figure that out. That's very important, not just for the physicians and their patients, but for the hospital system trying to prevent unnecessary emergency room visits, hospitalizations, readmissions, and untoward complications.

Physicians Practice:  What can physicians and other practice staff learn from your experiences at MD Value Care?

Gerard Filicko:  I think a lot of time you get physicians so overwhelmed by what this new environment is going to bring that they don't feel they have the capability of staying independent. They say, "No, the only thing we can do is get bought out." You have hospital administrators - and I know, because I used to be one - who come in and talk about all these great things they can do [for the practice] and that in order to succeed, you should get on their team. What Stephen and I hope to present [at MGMA15] is an alternate scenario that says you can maintain your independence, and here are some important considerations for you to be able to do that.

Stephen Cavalieri, MD:  There's a big step to go from the fee-for-service environment into the value-based environment and often times, practices and physicians find themselves with a foot in both canoes not knowing which way to lean.  Physicians find that this transition difficult. We both want to provide a sense of how this transition can be eased. There is iterative work involved and there is value to be derived from that work.

Physicians Practice:  What are some keys for physicians to consider when weighing participation in an ACO?

Gerard Filicko:  The first one is choosing your partners. When you go into an ACO environment, these are multi-year contracts - two years, three years, five years, or even longer - and you have fiscal responsibility for maintaining the health of these patients over the course of the contract. From a patient care standpoint, you really need to maintain that long-term relationship. That's the whole point of medicine. It's at the heart of it. But it’s also important to look outside of your practice - whether you are a primary-care physician looking at specialists, specialists looking at hospital systems, or looking at the role of home health, etc. - you need a framework for choosing those partners, how to ensure they are the right ones.  You will need new structures and governance in place, as well as administrative procedures to make sure all of your incentives are aligned and that you've got the right ability to manage the various contracts that come.

Also, physician groups should have a well-structured plan in place to be able to operationalize your transition from fee-for-service to value-based care. What I mean is: Do you have a way of identifying yo

ur patients that need service – your healthy patients before they become sick, your moderately ill before becoming high-risk? Do you have a means of capturing and identifying your patients that have been released from the hospital? Do you even know who all your patients are? Do you know when they've been admitted and/or discharged? Do you have a means to capture the quality metrics all of these new contractual relationships require? Is your EHR capable of spitting out the information you need and are you using it the right way?

Stephen Cavalieri, MD:  From my standpoint, it's also about capacity. The demands of value-based care challenge the components of the practice. Your administrator has got to be flexible, smart, and have IT understanding or an IT manager, because there are IT demands here. Office workflows need to be adjusted to achieve value-based metric success.  Some practices come to realize that this may reduce their daily patient capacity. 

And then, from a physician standpoint, doctors don't always immediately become comfortable that there is a care manager involved. Care management is vital to success in value-based care. And so it's a question doctors need to ask themselves: Are they ready to have another human being [whether it is the care manager or another physician] involved in the care of their patient? It takes time but most physicians see the value and the offset in their busy day.

Sometimes it takes direct physician-to-physician communication to achieve to achieve comprehensive physician understanding of the care management process.  Our team has expended lot of face-to-face and telephone time within our ACO practices to accomplish this. Our nurses, our social workers, and care management leadership have spent significant time in practices promoting a deep relationship.

Stephen Cavalieri, MD and Gerard Filicko are featured speakers at MGMA15. Their session, “Your Declaration of Independence - Creating an Infrastructure for Population Health,” is scheduled for Monday, Oct. 12, from 10:30 a.m. to 11:30 a.m.