Independent Practices Can Succeed in Risk-Based Care

Risk-based contracting is a viable option for independent physicians so long as they believe in why they are doing it, they know how to get it started, and figure out what they have to do to thrive.

Those were the musings of Farzad Mostashari, the former U.S. National Coordinator of Health Information Technology and current CEO of Aledade, an accountable care organization (ACO) services company. Mostashari spoke at the 2015 Medical Group Management Association (MGMA) Annual Conference, held in Nashville, Tenn., focusing on the why, how, and what of taking on risk-based contracts, if you’re an independent practice.

Mostashari began the session with a simple mantra: “If you don’t believe in this, don’t get involved.” The most successful risk-based organizations find opportunities to improve. He said physicians who take on risk-based contract arrangements just for the sake of doing it will not be successful and would be better off staying in a fee-for-service world.

However, Mostashari noted those physicians should change their thinking and get involved with risk-based contracts, through ACOs, Patient-Centered Medical Homes (PCMHs), or another model. He said eventually, the health system won’t be able to support itself, with costs continuing to rise ($3 trillion every year) and care failing to improve.  

He lamented that healthcare dollars today are spent after the patient has an encounter, not before.  “Once a patient has had a stroke, we’ll spend anything. To prevent the stroke? Is there a preventive stroke code? There are a lot of ICD-10 codes. Is there a single one for keeping the patient healthy?” Mostashari asked. “That’s the problem with the current system.”

The Quest for Value-Based Care

Continuing on, Mostashari said a physician’s conflict between knowing what the right thing is for the patient versus knowing what the right thing is for the business of healthcare, “rips at the spirit of healthcare.” The former government official called regulatory compliance “the enemy of why,” as in why doing value-based care is the right thing to do. Providers don’t want to go broke doing the right thing.  Mostashari urged attendees to be “knights” and take on the cause.

In terms of how practices should get a risk-based arrangement off the ground, Mostashari boiled it down to a simple mnemonic device: “I decide to cha-cha.”

“I” stands for incentives matter, as he urged attendees to align incentives with outcomes. “Decide” means practices making the decision to commit physicians and staff to change. The t in “to” is making sure your organization teams with the right number of partners and is working with those who share the same goals. “Cha-cha” is short for organizations have to understand what they have changed and assess whether it worked or not.

In working with ACOs, Mostashari said when he inquires what they changed and the answer is incorporating monthly meetings, he asks the same question again. When the real answer is "nothing" has changed, "then nothing will happen," he said.

Risk-Based Success

Mostashari then told attendees what they had to do to thrive in a risk-based setting. First and foremost: “Know your patients,” he said, adding that attribution is one of the “fuzzier” parts of ACOs and PCMHs. If a patient sees another provider, a practice can lose attribution.

“So what’s the solution? You need to put your arms around patients, see them, let them know you feel like you have a special relationship with them and if they are in the emergency room, they should call you,” Mostashari said.

The second step, he said, is to identify high-risk patients. This can be easier said than done, he noted, adding that it’s important to ensure whatever technology tool a practice uses for this purpose has to give it a significant return on investment. The last steps to thriving in this environment include telling patients about value-based features, such as same-day visits, and ensuring an organization is referring its patients to a value-driven specialist during transitions-of-care.

Mostashari offered his final piece of advice to potential risk-based contract participants. He said if the arrangement doesn’t appease patients, providers, or payers, it won’t work. “Every effort at healthcare reform has failed because it ticked off one of those three parties,” he said.