Evolution of Health Care: Bridging the Clinical, Administrative and Financial

By | June 27, 2018

By:  Frazer Buntin & Kate Rollins

The new skills required to operate a value-based care business successfully are vast, and the financial return becomes viable only if a provider can go at-risk for enough lives to scale their investment. This reality is a major inhibitor to providers who want to move up the risk continuum and for those who tried and failed. Unfortunately, many value-based care (VBC) initiatives fall at the lower end of a spectrum of accountability, amounting to little more than glorified pay-for-performance tasks that check the box for bonus dollars. This doesn’t drive accountability into the care delivery system in the same way that taking on both upside and downside risk does. To effect lasting change, providers are moving up this continuum of risk-taking through mechanisms that allow them to capture more of their generated savings, but also hold them financially accountable for losses—such as Next Generation ACO or Medicare Advantage for Medicare populations.

Providers making the move toward risk are balancing the in-sourcing of new skillsets with outsourcing to third parties. Those who are seriously committed to VBC as their path forward are looking for partners that can help them rethink and redeploy their clinical model for effective population health, get technology in place to enable clinicians and administrators to operate effectively, and, for the most sophisticated, run the back-office administrative components that are culprit cost drivers, but which providers must own if they want to capture the maximum financial gain from the value they’re creating.

The way the industry is evolving, and where providers are innovating in the space, is bridging the clinical, administrative and financial:

  1. Clinical:

CARE TEAM PERFORMANCE: Using a care team to support high-risk patients is not a new concept, but has traditionally been challenging to directly measure impact/ROI. Having a concrete process and key performance indicators for care managers helps providers identify exactly what tasks correlate to improved health outcomes and lower costs. It also helps identify high and low performers so teams can replicate the best practices of the highest performers and deploy skills training for those who need coaching. Getting smarter on how to orient expensive clinical resources and directing that attention where the care team can make the biggest impact is a different construct than yesterday’s disease management programs.

COMMUNITY HEALTH WORKERS: In one program, a provider deployed Community Health Workers as part of an extended care team for Medicaid populations. In a preliminary analysis of the impact on the care team’s workload and productivity, early data suggest that care managers can nearly double their case loads after successful introduction of Community Health Worker support. This could have major implications for how the industry thinks about creating capacity for both doctors and nurses, what roles are needed in the healthcare workforce at large, and the benefits of a community-centric approach to operationalize and deliver care. It also has implications for avoiding physician burnout. The more productive the care team is that supports that primary care practitioner (PCP), the more that PCP can trust that patients are followed and continually engaged outside of the point-of-care office visit. This helps them succeed at population health without taking essential time away from other practice areas, and sets them up for a better relationship with the patient when they’re face-to-face.

CLINICAL PROGRAM INNOVATION: The same provider is also engaged in a partnership with in which some of their partners are piloting new clincial programs for targeted populations. One in particular is a pilot to prevent chronic kidney disease from escalating to end-stage renal disease. What’s interesting about this partnership is that the provider is helping their partners take the best academic models and determine how to operationalize them on the front lines. The provider is working to iterate, test and titrate at the population- and disease-specific level to drive better patient experience and health outcomes. The goal is to refine the approach and then scale it to the provider’s numerous national partners nationwide.

2. Administrative:

THIRD-PARTY ADMINISTRATOR (TPA) CAPABILITY: To capture the value that providers can create through clinical impact and savings, they need to be able to administrate claims, run effective utilization management and pharmacy benefits management, and in some cases support member services with call centers and staff. These aren’t traditional areas of expertise for a provider, but helping them take on these administrative services is beneficial.

POWER OF CLAIMS PLUS CLINICAL: One provider successfully integrated its claims administration platform into a core population health data analytics technology, last year. This means that their partner now has claims processing and data operating on the same scalable platform as their clinical and financial workflow tools. Claims traditionally have months of lagtime before they can be used to help identify patients who may need care management support. With the stratified clinical platform, knowledge about which patients may be high risk for an acute event can be quickly spread across the care continuum, and lead to accelerated conversations with the patient and her PCP. This helps achieve the ultimate goal of intervening before a medical event occurs.

3.  Financial:

FINANCIAL METRICS ARE DIFFERENT FOR VBC: When providers effectively learn the new clinical and administrative skills they need to be successful in risk, it drives financial performance, as well. Providers benefit from having reporting and analytics on the same infrastructure as their clinical and administrative tools. In the value-based care world, they need to be able to track, report and manage based on contract terms that work differently than fee-for-service.

FINANCIAL PERFORMANCE READINESS: Providers participating in Next Generation ACO are faced with a complex financial situation. They need to monitor performance on clinical outcomes for a specific group of Medicare beneficiaries throughout the year to know if they’re on track to achieve savings or not. Knowing the financial trend of the value business early on creates opportunity to change approaches mid-year for a better chance at achieving savings targets. However, to do this effectively, providers need to get started before their performance year begins with CMS. They can deploy tools several months prior to the performance year to start analyzing and assessing the probable risk of their Medicare panel, get people in early for preventive care, and jump start the clinical program design process so that the entire care team can make a difference on day one of the performance year.

KEY TAKEAWAY: Any given provider could pull all of these levers and still not see an ideal return if they’re only doing it for a few thousand patients. Once infrastructure and process is in place and there’s a roadmap for success via a smaller population test case, providers are then ready to place more risk lives under management. How they accomplish this depends uniquely on the dynamics of their local markets, which drives the wide variety of business strategies across the country. For instance, some take their PSHP to new geographies to get more membership; some create alliances with other provider groups to get more patients attributed to a successful ACO; some have immediate scale if they’re granted the opportunity to manage hundreds of thousands of Medicaid beneficiaries. Regardless of which strategy providers choose to navigate the shift to value-based care, it’s clear that they’re on the right track to serving a common goal of improving health.

About the Authors: Frazer Buntin is the President, Value Based Services, and Kate Rollins is the Vice President, Clinical Programs and Performance, at Evolent Health. They can be reached at FBuntin@evolenthealth.com and KRollins@evolenthealth.com.