As Value-Based Care expands, payers are emphasizing cost reduction all the more. Newer CMS payment models like ACO REACH reinforce cost control by capping reimbursement in total global payments to ACOs. In turn, global payments enable ACOs to directly negotiate rates with preferred provider specialists.
In addition to focusing on controlling costs delivered through primary care, your ACO should pursue strategies to stem total patient care costs (TCC) through specialty services. Between 40 to 60 percent of total patient care costs are driven by specialty physicians. While rate negotiations address the price of individual specialty services, the greater opportunities lie in addressing cost variation of services, outcomes that drive up utilization and cost, and avoidance of low-value services.
For specialists participating in your ACO panel and for your referral network, you have the opportunity to develop strategies that are win-win for both you and specialists. It just takes a collaborative attitude and data. These five tips show how:
- Create a data sharing relationship that includes aggregation of patient data as part of your collaboration. Many specialty practices do not have this capability. They may depend on their EHRs to perform quality reporting, but the value of data goes well beyond these basics. Data will help specialists address other issues, such as cost variation and variable outcomes. The specialty group will want to keep some financial data private, but if you are already aggregating your participating provider EHR data and integrating claims, you can use the claims data to calculate costs for payers that provide it. The data is essential for the next step of identifying cost issues.
- Create episodes of care for high-volume procedures and conditions to generate comparable patient events for examining cost variation and outcomes. Share the results with specialists and start the conversation about why the variation occurs and ways to mitigate. An analytics vendor capable of creating episodes with clinical elements to provide insights to how these have affected cost or quality will help your ACO and specialists. Eventually, your episodes may become part of an overall, results-based scheme to include specialists in your network.
- Provide specialists with seamless access to the ACO Value-Based Care technology for viewing their patients’ comorbidities and relevant treatment plan/population health information. This provides an avenue for specialists to create strategies to help guide their own services to these patients and to prevent specialty treatment complications.
- Help specialists succeed in quality reporting. MIPS or other quality scores can be one criterion for selecting specialists for your referral network. While not perfect, these scores can flag issues to discuss and ensure that there is an effort at consistent, evidence-based medicine within the practice. Furthermore, as specialists become eligible for MIPS Value Pathways (MVPs), CMS is asking ACOs to encourage MVPs among specialty physicians. By ensuring aggregation of specialty data and assistance with quality reporting services, you can make it more economical for the specialty group and more beneficial for you to enable their MVP reporting.
- Involve specialists in ACO improvement programs. Your strategies for improving care and related costs are exponentially increased with the involvement of specialists and the use of episodes. By collegially designing pathways for chronic conditions that establish criteria for referrals, medications, and population health, you can engage specialists in success for your ACO—and for their own practices.
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