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- Value-Based Specialty Care Part II.
Hi friends!
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Welcome back for Part II of my perspectives on Value-Based Specialty Care and where Episodes of Care models do and don’t overlap.
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In last week’s article, I first covered who the primary care provider types actually are. These are the providers who will more and more be moving into team-based, full-risk, advanced primary care practices. I see this as an inevitable.
Then I shared the different “types” of specialists (how I think about them, and not a universal definition).
Specialists will be impacted differently, depending on their “type.”
So last, I broke down specialty care types to describe potential impacts of advanced primary care on specialty care.
Because through total cost of care models and advanced primary care prospective payment models, CMS will facilitate downstream impacts on specialty care types in different ways.
If you only have a chance to skim this now, save as a reference for later. I like Notion and mymind for saving resources, takeaways, as “read later” apps and as my “second brain.” They both have great Chrome Extensions and make saving on mobile easy, too!
I use them to save other newsletters I receive by first hitting “read online,” and then saving the page with a brief note about any new connections it helped me make or how it can be helpful as a resource for a project, or even just put it on my reading list for the week!
One more thing:
Definitely don’t miss The Business of Healthcare podcast episode I linked at the end of the article. Worth a listen while you commute or do housework! 🚗🧹
Advanced, Team-Based Primary Care Taking Full Financial Accountability for Their Populations will Impact Specialty Care
And I suspect impacts will be seen first in utilization of chronic disease specialists.
Specialty Care will be impacted by advanced primary care.
Then consider the impact of episodes of care models, which overall haven’t impacted specialty care practice or move to value significantly (because the incentives are weak and the levers for the physicians are few in episode).
BPCI-A and CJR mainly impacted post-acute sites of care from the perspective of financial loss. The incentive in acute episodes is to reduce spending outside the hospital, after the acute care hospital stay, for the hospital, attributed physician, and/or convener to earn up to 20% of the difference between the target price and the actual cost to provide care under Medicare Parts A and B in the episode.
While CJR was mandatory in certain MSAs, it was limited to a few surgeries by the same surgical specialty type. And with SO MUCH low-hanging fruit to reduce the spend outside the hospital, some hospitals did little to change their own operations to contribute to that savings.
BPCI and BPCI-A were voluntary, and attrition was high when the “ratchet” of lowering target prices, managing post-acute, and arbitrage dynamics made the program too hard to succeed, many deemed.
In comes the TEAM model.
Thirty day episodes are different. There’s less time to save unnecessary and low-value episodic spending relative to the target prices that are now 90 days.
Less time to facilitate discharges from inpatient post-acute settings and back home, especially for SNF where the SNF is losing money for every day less a patient stays.
The levers will be different.
Optimizing the hospital stay will be crucial to success.
What I touched on briefly was the greater need by each hospital to work proactively with the surgeons, consulting providers, clinical and operations staff, and others.
Since all hospitals in the CBSA will be participating, universal regional hospital adoption of improvement standards would make sense, assuming target pricing strategies don’t inadvertently disincentive that.
A few levers to address with medical staff:
Follow the most up-to-date, best practice guidelines for use of anesthesia, blocks, pain medication regimens.
Roll out universal mobility orders, with justification needed for bedrest orders to remain in place.
Optimizing patients prior to elective surgeries, when safe and reasonable. 👇️
HgbA1C above 8 or 9? Work on it.
How?
Collaborate with the advanced primary care practice and the clinicians supporting patient engagement and behavior change.
Patient doesn’t have a primary care provider?
Identify the high-value providers in the area and directly refer.
BMI above an agreed threshold?
Address it first.
How?
Collaborate with advanced primary care. See above ☝️
So TEAM hospitals will ideally evaluate all opportunities to improve how care is delivered, put the right protocols in place, address culture change barriers, optimize staffing for non-physician/non-APP staff that hospitals don’t normally consider when there is little impact in PPS.
Walk in the park! 🤣
Do you have sufficient rehabilitation staff, social work staff, mobility program team members?
Do we need to add transitions of care navigators?
Thoughts to ponder!
Will hospitals convince surgeons to collaborate on and support the cultural and operational changes needed for strong performance in TEAM?
Some will, yes.
Some will have some challenges.
Some will have an uphill battle.
In the first five episodes types proposed to be rolled out, most of the opportunity for pre-op optimization is with orthopedists.
As many have experienced in prior and current episodic models, it can sometimes be hard to create meaningful incentives for well-compensated surgeons to change.
It can be hard to convince a surgeon to talk to patients about postponing a surgery, planning for a discharge home and the relevant coordination involved, coordinate with primary care practices, and have conversations with patients about their modifiable surgical risks.
Also, all the surgeons performing the procedures included need to get on board together.
If a hospital’s readmission or complication rates (or other quality metrics) have improvement opportunity related to these procedures, will the surgeons and hospital collaborate on process and quality improvement?
More to ponder.
Reminder: Episodes of Care and Specialty Care are not one and the same
I say this often because it’s I believe it’s a perspective to embrace if you want to pull the right levers for success.
Specialty care opportunities can be found well upstream from the hospital.
Acute episodes of care only have upstream incentives for surgeons for planned/elective surgeries.
The toughest episodes to manage are generally complex patients with multiple advanced comorbidities at high risk of complications during and after hospital stays. Many are seriously ill. Many have repeated hospital episodes of care.
As ACOs and other at-risk providers become more experienced in VBC, they must actively participate in the episode.
But you know one of the best things these surgical episodes should hopefully do?
…episodes that aren’t influenced nearly as much by upstream care as BPCI-A’s chronic, complex medical episodes?
They will allow hospitals to build muscle memory in transforming acute care delivery to set an episode of care out on the right path.
Those that haven’t had any exposure in BPCI-A or CJR will be more heavily weighted in the selection process to build their experience.
Specialists themselves must be engaged in specialty care model care transformation like Kidney Care Choices and Enhancing Oncology Model.
Specialist participation is not the primary or even secondary lever in most acute episodic models condition types.
Acute episodes of care management mostly impacts Medicare Part A spending and quality of care.
There is upside in this for hospitals, despite their concerns.
One guess who stands to lose financially as acute episodes of care management become mainstream.
Skilled Nursing Facilities more than anyone.
But there are things SNFs can do to get ahead of this if they choose to.
On that note—an upcoming newsletter issue (or issues) will cover my predictions about the future of skilled nursing facilities in a value-based, reducing fee-for-service population world. Hint: the predictions haven’t changed much since 2015. I just know changing healthcare delivery and related policy is a long-term process.
There will always be a need for acute episodes of care management while PPS’ Medicare Part A FFS incentives are strong
In a future state, the inpatient sites of care incentives will need to align with total cost and quality of care incentives.
This won’t happen tomorrow.
But we have to keep up the momentum with the tools available.
Specialists can be influenced to collaborate with total cost of care models on their shared patients through Innovation Center programs, the Quality Payment Program and MACRA reform, and health policy changes related to how physicians are reimbursed by CMS.
There are already specialists from surgeons to chronic care illness specialists who are ready and willing to participate in care transformation.
Keep an eye on this:
Watch Making Care Primary’s Track Three Participants as the model launches this summer
Will they make successfully use the “MEC” and “ACM” with partnering specialists AND will that impact longitudinal spend? 👇️
So, Why is it Important to Understand the Implications of CMS’ Value-Based Specialty Care?
After all that, what’s my point?
Health care delivery transformation will be the most important lever in the long-term success of value-based care.
Here’s what that means for the “boots on the ground:”
There are opportunities to develop business solutions and/or identify risks right where you are working now. Clinicians who want to move to non-clinical work—this is your call-to-action. Use your clinical perspective and the new incentives and sketch out a solution. What is the value-based care local landscape? What could be changed that would help your organization be successful? How could you demonstrate the return on investment of resourcing what you recommend? 💬
For physicians and APPs who can hold patient attribution to alternative payment models: if you aren’t yet involved, it’s a great time to get in. Build the foundational skills by participating in a model like MSSP Track A with upside-only risk. You still have a little time left to apply for 2024. And make sure you check out the Advance Investment Payment option, which was new in 2024. 👀
If you are a specialist physician, it may be helpful to know your value and efficiency from a data analytics perspective. When advanced primary care providers at full risk are looking for specialists with whom to refer and collaborate, they will (and are) using that data. Given your local area, is there value in finding out how you compare with your peers and what might influence that to matter more in the near to mid-term?
If you are a physical therapist (or OT or SLP), you have never been more valuable than you right now. Demonstrate that value to at-risk providers. Collaborate in a synergistic way. Behavioral health providers are showing you the path. Follow it.
If you are a nurse, your inherent, deep value both clinically and in connecting with patients is critical to VBC success. VBC can’t achieve its goals without a strong partnership with nurses right from the start.
For the many non-clinicians working in a wide variety of roles across the healthcare and health tech industries, expertise in value-based care will be a primary consideration for career advancement opportunities. There’s still so much opportunity to build that expertise!
Want to chat with me directly about it? There’s a link to book some time with me (before and after normal business hours; weekend slots are also available) in the email footer. 📆
It’s a great time to get excited about health policy’s direct influence on strategy. The ones with the policy knowledge will be highly valued!😁
I very recently added a survey for new subscribers to complete when they sign up to receive the newsletter. It’s a 30 second survey. It would be SO helpful if the hundreds of subscribers who have been receiving the newsletter prior to the last issue could also complete it. 🙏
Check this out! 👇️ 👂️
At about the 28 minute mark of this podcast, hear Eric Bricker, M.D., explain how one health system has managed the drop in their specialists’ utilization and kept them whole (because advanced primary care so greatly reduced the need for some specialty care):
Last but not least—tonight (5.7.24) from 7-8 p.m. ET, I’ll be presenting on value-based specialty care to the Humans in Healthcare community and to my paid subscribers. Premium subscribers will receive an email link to invite you to join later this afternoon.
Thanks for reading (or saving and reading later 😃)!
All the best,
Dana