Challenges loom in the areas of payment, patient access, consumer engagement, population health management, and provider alignment.
For medical groups, the last few years have been tumultuous with the shift to value-based care. In 2017, medical groups will continue to experience change on all fronts, including payment, care delivery, and interaction and communication with patients. Medical groups must contend with new payment models, fierce competition in their markets, increased regulatory requirements, clinical advances, digital and information technology changes, and population health management implementation.
In response to these shifts, medical groups should focus on five key areas to position themselves for the future. As Socrates said, “The secret of change is to focus all of your energy not on fighting the old but on building the new.” And that is what medical groups need to do in 2017: build the new by transforming the old ways of practice management.
New Payment Models: Focus on Quality and Cost
Depending on geography, “value-based contracts” range from fee-for-service arrangements with incentives for value to 100 percent risk-based agreements. While the degree varies by market, commercial insurance plans will tie more payment to value and risk in 2017. Medical groups will be faced with increased pressure from payers to assume additional risk for the delivery of high-quality care at lower costs.
To succeed under new payment models, medical groups will need to transform their practices and consider new capabilities and the resulting implications for care delivery and management. Potential outcomes include better-coordinated care at a lower cost, a positive social reputation, and financial rewards.
Reporting under the Quality Payment Program (QPP) of the Medicare Access and CHIP Reauthorization Act begins in 2017 (MACRA). Medical groups need to determine their QPP payment track: Advanced Alternative Payment Models (APMs) or the Merit-based Incentive Payment System (MIPS). To be successful under either, groups are required not only to track measures and activities but to perform well in those areas—and even to outperform their peers.
Medical groups should have a plan in place in preparation for MACRA, including the selection and implementation of specific measures and activities. Groups should establish a plan for monitoring performance to ensure high performance compared with peers. MIPS groups should develop a strategy and timetable for transitioning to the APM track, which offers bonuses and removes some of the reporting requirements that practices face under MIPS.
In addition to the start of MACRA, Medicaid expansion continues throughout the country (the future of Medicaid expansion after the recent election remains to be seen) and Medicare Advantage plans continue to grow. Success in these areas likewise requires an emphasis on providing high-quality, coordinated care while reducing the medical spend.
To be effective, the care delivered to patients, specifically those with a chronic illness, needs to be managed across the continuum. Medical groups need to work and align with other providers of care, such as hospitals, surgery centers, and post-acute facilities. To support care delivery across the continuum, components such as technology, care protocols and care management, and a focus on primary care services are critical.
Focusing on primary care services may require changing staffing models to support efficient care and to demonstrate quality. Any staffing model needs to be evaluated to ensure an appropriate mix of clinicians as well as to determine whether staff and clinicians are working to the top of their license.
Ideally, physicians should focus on revenue-generating work, while support staff such as nurses, medical assistants, and administrative staff perform other activities in accordance with their scope of license and their abilities. These activities may include clinical work such as taking patients’ vitals or history, appointment scheduling, patient education and callbacks, and triaging.
A practice may need to consider adding midlevel providers and other clinicians to help manage and deliver the care to the patient populations served by the medical group. Practices also should determine whether the behavioral health and socioeconomic needs of the patient population are being served.
Patient Access: Focus on Innovative Care Models
The healthcare industry is experiencing significant shifts in the way care is accessed and delivered, and medical groups need to build strategies to expand patient access and engagement, increase and retain market share, and minimize their risk in value-driven payment models. In simpler terms, medical groups should focus on improving patient access by providing the right care at the right time in the right setting, with right defined by both patient preference and clinical criteria.
Recently, a variety of high-tech and high-service medical groups have entered the market. Many of these are for-profit venture-backed companies that are taking advantage of traditional physician practices’ lack of patient access and service. To thrive, medical groups will require innovative care models that lead to better care delivery at a lower cost, patient retention, and increased patient satisfaction.
Patients are demanding immediate access to care, convenient hours, and multiple ways to communicate with their physicians. They want to be able to navigate the system to find the right care at the right time. Medical groups need to assess the patient experience from the patient’s perspective: What is the patient experience like in the practice? How do patients navigate their care? How does the medical group support the process? How does technology, such as patient portals and online options, support patients to ensure they receive the right care at the right time?
Care delivery is changing. Consumers are seeking convenience and are increasing their use of technology; depending on the situation, care can be provided virtually. The use of telemedicine will not only increase in remote rural areas but will be used by patients who don’t want to leave their home for care. Patients are accessing care and “seeing” their physicians on their cell phones. Many payers, including Medicare, are expanding coverage for telehealth and even behavioral health services that are delivered virtually. The use of mobile technology and applications for telehealth and self-monitoring is exploding, allowing, for example, patients with complex conditions and the elderly to be managed more effectively.
In light of these developments, medical groups should examine their virtual-care and telehealth offerings and strategies. What technology does is being promoted to the patient population?
Consumerism: Focus on Customer Service
Consumer-driven health care is on the rise. Patients have options when selecting their coverage policies, with many choosing high deductibles and accepting responsibility for a larger portion of the cost of their care. In turn, patients are becoming more familiar with the process of actively choosing providers and services; medical groups need to be cognizant of that dynamic.
Additionally, new competitors such as retail clinics, virtual and telehealth providers, home healthcare providers, and others are entering the marketplace and offering patients more convenience, more choice, better service, and in many cases more affordable care. How should medical groups respond to these competitors? The consumer experience, as well as the consumer’s preference, matters significantly.
Maintaining or, better yet, building patient loyalty becomes an important driver of patient retention. Consumers expect information—not only about their health condition and treatment options but also their coverage and the price of their visit, among other issues. When group practices attend to the consumer, the result is higherpatient engagement, which correlates to better care and overall outcomes—not to mention an increase in patient satisfaction and a positive reputation for the medical group. Satisfied patients also are more likely to pay their bills, leading to a decrease in the cost to collect.
Understanding the distinct patient population by performing market studies, then segmenting consumers into groups (e.g., age and condition, demographic, mental health needs) will provide medical groups with insight into what matters to their patients—including consumer preferences and how they want to be engaged—thereby allowing the group to meet those needs.
For example, new mothers may be seeking a social outlet for information about infant care or breast-feeding, perhaps via education, a portal, or even a Facebook group. Older patients diagnosed with uncontrollable diabetes may need group support or behavioral therapy. Many surveys suggest that the most important issue in a patient’s experience is the way in which staff and providers treat and communicate with the patient. Organizations such as Cleveland Clinic even have their employees undergo empathy training to better relate to patients.
In the age of consumer-driven health care, patients have high deductibles and responsibility for a larger portion of the cost of their care. In essence, “patients” may be one of a medical group’s top payer categories. For this reason, price transparency is important as patients potentially shop around and seek low-cost providers. Additionally, collection from patients is more costly and has a lower collection rate compared with collection from insurance carriers.
Medical groups should ensure they have a solid financial policy in place that addresses patient collections, along with methods to collect patient-due balances such as self-service options and keeping a credit card on file.
Population Health Management: Focus on Data and Analytics
Typically, medical groups do not have the requisite data for obtaining the information they need to manage patients across the continuum of care. Yet they are held responsible for the cost and quality of the care of a patient population (factors that help determine payment).
For this reason, medical groups must strive to understand their patient populations, manage their care better, and know where they are going and what kind of services they are receiving. The risk environment makes it especially important for medical groups to have strong transition-of-care and care-coordination technologies along with protocols that maximize the efficiency of the care. These elements are necessary to ensure optimal care management, reduce cost while improving quality, and maintain or increase referrals.
For medical groups, managing patient populations takes a concerted effort to partner with other providers to share and exchange information. Medical groups must optimize the use of their electronic health records (EHRs) to support care management across the continuum. In addition, MIPS measures address the advancing of care information and the interoperability of systems. For example, clinicians are required to exchange electronic summary-of-care documents during care transitions.
A data-source gap exists for many medical groups, with claims data and data from other providers not aggregated for analysis. However, medical groups can use the data they have from their EHR, practice management system, and registry; and from payers, a physician-hospital organization or clinically integrated network (CIN), the Centers for Medicare & Medicaid Services (CMS), and other sources.
For example, CMS’s Quality and Resource Use Report (QRUR) shows clinician or group performance on quality and cost measures, including the per capita costs (or medical spend) for specific conditions such as diabetes, COPD, CAD, and heart failure. These costs are based on payments for all medical claims submitted by providers, including Medicare Part A and Part B, which includes providers that do not bill under the group’s taxpayer identification number.
Practices that participate in Medicare Advantage plans should be reviewing their scores and ensuring that providers are accurately coding. Under many new payment models, diagnosis coding drives risk adjustment and ultimately payment. Practices should consider implementing reviews, provider education, and system edits to support accurate coding.
Medical groups should review their QRUR report or other payer data and consider what the data reveals about ways in which patients may be better managed. In general, groups should understand how payers are linking quality and cost to payment and make efforts to review and understand accessible data.
Improved Care: Focus on Network Alignment
Consolidation will continue across the healthcare industry, and hospitals and health systems will continue to acquire and employ physicians. However, physician employment is not the only strategy. Alignment with all providers across the continuum of care is the real key.
Insurance plans and providers, including medical groups, are collaborating to offer high-value, low-cost plans. To better manage care delivery and costs, narrow networks allow consumers to save money and get the care they need within a network of participating providers in an organized system of care. When medical groups work together across the network, the results include better care, shared data and access to technology and care management support, better contracts and network participation, and referral retention.
Hospital, health systems, and other organizations continue to form CINs to respond to changing healthcare dynamics and to promote value-based care. CINs are designed to control costs and ensure care quality by managing patients and focusing on the goals of the Triple Aim. Forming a CIN is a physician alignment strategy, with physicians providing leadership and focusing on clinical quality improvement and efficiency, as well as appropriate utilization management.
For medical groups, the value proposition of participation in a CIN is alignment with a system to preserve patient volumes and referrals and to provide an opportunity for better payer contracts. Additionally, CINs support physicians by providing an infrastructure, including technology, analytics, and care management.
A Year of Challenges, Opportunity
In 2017, medical groups will continue to experience change and feel pressure from consumers, payers, other providers, and new competition in the marketplace. This year promises to be one of change, threats, and opportunities for medical groups, which must take action to survive and outperform the competition.
The overarching task for medical groups in 2017 is clear: build the new by transforming the old ways of practice management to meet the demands of the consumer, compete in the market, and provide better care at a lower cost.
Lucy Zielinski is vice president, GE Healthcare Camden Group.