November 20, 2020
To successfully manage the 40 to 60 percent of costs of care driven by specialty physicians, your ACO must overcome one major obstacle when you begin to address specialty costs: the lack of information to guide your actions. Although ACOs have claims data to calculate total costs per ACO patient and totals for specialty services, you can't compare those costs. Why? Claims are not organized into cases or "episodes of care" that include all providers and services so that it is easier to compare case costs between patients or providers. More importantly, the small number of Medicare patients seeing any…Read More
September 10, 2020
Three Fixes for ACOs’ Physician Engagement Strategies
ACOs know that reducing costs is the key goal for Value-Based reimbursement. But strategies on how—or even whether—to engage physicians in that goal have not always been successful, to the detriment of all involved. Part of the problem is that provider revenues still stem from Fee-for-Service payments. Physicians are still rewarded based on meeting volume of patients and revenues. Even if participating in an ACO, your physicians get very clear messages about meeting volume and revenue targets. Hospital and health system-based practices survive by ensuring that volume is maintained—especially in these times. As health plan capitation and new Value-based risk…Read More
August 12, 2020
How ACOs Can Control Costs with Physician Help, in 3 Steps. Really.
Health care has been drained emotionally and financially by the COVID-19 pandemic. Yet, in a surprising twist, that trauma has accelerated providers' willingness to adopt financial Risk. You may be one of many providers who have suddenly realized the value of predictable revenues like capitation. Receiving continual payments for attributed patients is appealing, especially when deferral of routine care has led many practices to the brink of failure. That’s why many providers are specifically considering capitation. For Groups with previous experience in managing risk pools, it's an easier decision. But if you represent an ACO that resisted CMS Rules to…Read More
July 20, 2020
Episodes Are More Than Payment Models: They’re Key to Improving Care
For many health systems and groups, episodes are esoteric. Providers often think of them only in context of risk-based payment models like bundled payments and capitation. Navigating Value-Based Health Care contracts, providers analyze and model performance under Fee-for-Service and episode-based payments to decide their course of action. Or, if already in Value-Based reimbursement, they use them as targets for costs to pinpoint physicians who exceed the targets. These strategies are shortsighted and limited. Even at best, they do nothing to address what is actually driving cost of care. By using payer-constructed episode specifications, such strategies potentially obscure valuable clinical and…Read More
June 11, 2020
Is Telehealth Bridging or Widening the Health Care Gap? We Need to Find Out.
ROJI Health Intelligence CEO Theresa Hush frames the questions we need to ask about the future of telehealth in this 3:37 minute video. Telehealth has become the go-to solution for health care during the COVID-19 pandemic, enabling providers and consumers to remain in contact for routine and non-emergency visits while brick-and-mortar spaces have been closed. Now that health care is reopening, however, telehealth remains a preferred communications medium, and many providers plan to expand it much more going forward. So, it’s time to ask: Are the services we are offering through telehealth really delivering the best health care possible? And,…Read More
October 30, 2019
Is Patient Lock-In the Next Step in Value-Based Care?
Hoping to safeguard survival under financial risk, health care providers are courting a contentious issue: how patients select primary providers. During the HMO heyday , health care risk economics depended on patient selection of primary providers as part of coverage selection that “locked” them into those PCPs and their referral networks. PCPs operated as gatekeepers to the rest of the health care system, authorizing services (or not) for specialists and other care. It’s well known that the HMO’s Primary Care gatekeeper model generated a backlash among private sector consumers. In fact, the gatekeeper was so unpopular with patients that it…Read More
October 16, 2019
The Hedge Bet for Risk is Patient Experience
Creating a good Patient Experience in health care has gained little traction, despite being touted as one of the Triple Aim’s key goals in Value-Based Health Care. Health systems have been more focused on how to increase patients via health plan negotiations and consolidating regional providers, rather than focusing on the slower paced process of improving customer appeal. But now Patient Experience appears to be gaining some attention, and some forward-thinking providers are innovating to be more attractive to patients. Why? Because in the fiscal landscape of Risk, growing patient volume is essential. Providers are beginning to realize that there…Read More
October 2, 2019
How Consumers Can Choose Quality in Value-Based Health Care
In our last article on how Quality should be reflected in Value-Based Health Care, we looked at the problematic route of quality measurement and reporting. The intent to develop payment for quality has resulted in a complex measurement system that produced provider-specific performance scores across hundreds of measures, yet has failed to advance achievement of better health care outcomes. The system creates flexibility for providers by allowing choice of measures, which eliminates consumers’ ability to see differences among providers. The quality agenda needs to mature. In its developmental period, there was a need to achieve consensus on the standard of…Read More
September 19, 2019
Are Patients at Risk when Quality Measures Scale Back?
CMS is now poised to roll back quality reporting requirements in 2021, vastly altering the direction of quality measurement. Simultaneously, CMS will reduce the weight in Value formulas dedicated to quality, transferring the balance to Cost over the next five years. As providers face risk-based reimbursement, what protections are needed to ensure that patients get the right care? Does streamlining the program give providers a pass on quality? And, how do patients choose providers when there is no standardized measurement? In this second in our series on whether Value-Based Health Care is on track to meet its mission, we take…Read More
July 17, 2019
How the Stock Market Models a Path to Better Research.
The better clinical research is, the better medical care will be. It is so crucial to the future of best medical care that I have highlighted deficiencies of the present conduct of randomized trials (RTs) in previous articles to suggest ways to improve. A system of better research must accommodate studies on any intervention aimed to improve care, including interventions such as a change in practice, any quality or safety plan, or an economic principle such as fee-for-service versus capitation—not just studies of new drugs. In my last article, I coined the term “Gallup Research Medicine” as a model to…Read More