In value-based care (VBC), providers are expected to assume more financial risk than ever before. This can be overwhelming, as most physicians are accustomed to traditional fee-for-service payments, where they’re predictably reimbursed for every service they provide.
While fee-for-service is straightforward and reliable, there are problems with this payment model. For one, it can incentivize physicians to increase the amount of services they provide, regardless of whether they’re clinically necessary or benefit the patient. It can also lead to fragmented, inefficient care, which drives up the overall cost of healthcare.
For these reasons and more, there has been a growing shift over the past 10+ years for the healthcare community to adopt a value-based care approach, using alternative payment models in which providers take on more of the financial risk.
According to the Centers for Medicare and Medicaid Services (CMS), an alternative payment model “gives added incentive payments to provide high-quality and cost-efficient care.” In other words, rather than getting paid for volume of care, physicians are rewarded for the value of care they provide.
By assuming more of the financial burden, providers are drawn to make smarter, better-informed decisions about healthcare utilization. And for payers, compensation is tied to how well doctors lower healthcare costs and improve patient outcomes.
Overall, this shift leads to greater accountability among physicians — and if implemented correctly, the rewards can be sizable for providers, patients, and payers alike.
Even so, making the transition to VBC can be daunting, both administratively and financially. Many independent physicians may hesitate to make the leap for fear of financial strain and poor return on investment.
Fortunately for providers, many different types of alternative payment models exist, depending on the size and health of their population, the market in which they practice, competency, and what risk level they’re willing to assume. This allows them to ease into a value-based care model without the stress of full financial risk at the get-go.
Pay-for-performance (P4P) models (also called pay-for-quality) offer providers a way to dip their toes into value-based care.
P4P uses the fee-for-service structure, but providers also qualify for reimbursements and incentives based on predetermined quality of care, patient satisfaction, and cost savings metrics.
Private payers are starting to create P4P programs, but CMS has led the way, developing various alternative payment models that impact hospital reimbursement through Medicare — including the Hospital Readmissions Reduction Program (HRRP) and the Hospital Value-Based Purchasing Program.
P4P contracts do not require robust data analytics compared to other alternative payment models, so small practices that lack access to adequate technology to monitor and track data can still participate.
Some critics say providers may skew treatment regimens toward P4P practices, steering away from truly optimized care. However, studies show programs like HRRP have been successful, with hospital readmissions steadily falling since 2012.
Taking the next step in value-based care models involves participating in shared savings (also known as upside or one-sided risk) arrangements.
In upside risk, providers compete against certain predetermined benchmarks (for instance, ensuring that a percentage of patients with diabetes keep their A1C managed). If they meet the benchmarks and keep their total cost of care (TCOC) below the financial target, they share in the savings. However, if their TCOC exceeds the target, they’re not penalized or required to pay the difference.
Upside risk benefits providers because it allows them to keep some of the savings they helped generate. In fee-for-service contracts, the savings would remain with the payer alone.
Medicare Shared Savings Program (MSSP) is one of the biggest and most well-established shared savings programs.
MSSP is designed for accountable care organizations (ACOs) — networks of independent physician groups that share in the financial and medical responsibilities of a Medicare beneficiary population.
“ACOs bring multiple providers together, which gives them more scale and access to support services to drive performance,” explains Elizabeth Mills, Chief Financial Officer at Innovista Health.
MSSP requires ACOs to report on quality and cost metrics and provide coordinated care across all specialties. Everyone works together to streamline care and eliminate duplication of services.
In 2012, 220 ACOs existed, but today there are 483, collectively caring for 10.9 million Medicare beneficiaries (roughly one in 6 enrollees).
In addition to MSSP, CMS has introduced programs that allow providers to move to a downside risk model for Medicare, specifically DCE and ACO Reach.
In downside (or two-sided) risk, providers share in savings and risk. With these contracts, physicians receive allotted funds per patient and retain a defined portion of the surplus generated. However, if they spend more than they’re given, they are responsible for a defined portion of the deficit.
While there is much more financial risk, there’s also a greater opportunity for reward if the provider drives down the cost of care. Physicians can share in up to 100% of savings dollars.
Between 2012 and 2017, fewer than 10% of ACOs assumed downside risk. But as of 2020, that number jumped to 37%. This move to two-sided risk is expected to drive down medical spend by $2.9 billion over 10 years.
Because of the potential for losses, downside risk models are thought to more strongly motivate doctors to transform their practices to achieve the highest cost-saving potential.
In a bundled payment structure, an entity (physician group, hospital, etc.) is paid a fixed amount for all services within a single episode of care (joint replacement, pacemaker or bypass surgery, maternity care, etc.) or a specific period of time. Providers are responsible for all inpatient and outpatient care coordination for the specified episode of care or time allotment. They keep a portion of the savings if they successfully deliver care and prevent complications or errors, but if costs exceed the set amount, they’re responsible for the deficit.
One example of this payment model is the Bundled Payments for Care Improvement Initiative, launched by Medicare in 2015.
Downside risk payment models always involve capitation and/or delegation.
Delegation is where a payer transfers defined services from themselves to healthcare providers, such as claims, customer service, credentialing, or utilization management.
Capitation is an agreement where the payer establishes risk pools, usually a per-member-per-month (PMPM) dollar amount for every enrolled health plan member. The amount payers give physicians is based on the average expected healthcare utilization and risk profile of the patient pool, among other factors.
If the provider or group keeps their TCOC for the year below the capitated amount, they get to keep that money. Conversely, TCOC that’s higher than the capitated amount results in loss.
How do capitation and delegation work together, and how does that affect overall financial risk?
Mills explains, “If you are claims delegated and capitated, the payer is going to send you a PMPM amount, and you are responsible for paying all the claims across the continuum of care. If you’re capitated but not claims delegated, there’s no monthly cash movement. The payer will continue paying those claims and after the performance year, you will settle with the payer based on the surplus or deficit for the full performance year.”
The benefit of taking on delegation, according to Mills, is increased control and/or data availability. “For example, if you have claims delegation, you have the claims data in real time at the time of processing to react to.”
With that robust data comes the ability to better serve your population in the most cost-effective manner possible — which confers savings in the long term.
Providers interested in entering into a value-based care model ultimately need to decide what level of risk they’re willing to assume. Considerations include historical experience with taking on risk, access to value-based technology and support services, cash flow considerations relative to the funding timing of a given risk arrangement, and the potential deficit they are at risk to fund.
Furthermore, they need to really know and understand their population. For one, is it big enough?
Mills says, “Providers need to be cognizant of the size of their patient panels in determining the level of risk they are comfortable taking on. If your population is too small, it can be statistically challenging to perform, because if you have 500 patients and one very acutely ill patient, it’s hard to offset that level of medical spend.”
Providers also should have a good handle on their historical performance with their patient pool.
“The higher the level of risk a provider has taken on, the more data available to that provider to understand how well they have performed on a relevant population,” says Mills. “If you have a consistent history of performance and the tools in place to monitor your performance as the performance year progresses, that’s usually when you start to say, ‘OK, let’s take on more risk.’ If downside risk is a consideration, financial planning is critical to ensure you have the financial resources to sustain a potential loss.”
Finally, timing is important. Providers need to consider their multi-year plan on their pathway to risk, so that they can make sure they have the staff, partners, and technology in place to succeed and add risk when they’re best positioned to perform.
Stepping into a value-based care model has definite risks — but also plenty of substantial rewards, enabling providers to align financial incentives to better patient outcomes.
Physician groups can ease the transition into VBC by working with partners like Innovista Health, who understand the intricacies of payer arrangements and the importance of data analytics to drive better business and healthcare decisions.