On Demand Webinar | Intermediate | Contracting
A medical center CEO will explain his role in facilitating contracting collaboration with medical staff, health plans, and with legal council for effective and efficient implementation in executing contracts. Learn about successful tools, s...
Save
Course | Advanced | Contracting
This course provides an introduction to managed care contracting. The purpose of a contract and its key components are described. The course explains criteria-based contracting. In addition, it describes elements to monitor to ensure contra...
Save
Course | Intermediate | Contracting
This course discusses criteria to use in evaluating the written contract between the provider and managed care organization, which defines the rights and obligations of the parties under the health plan/provider relationship. It also define...
Save
Case Study | Contracting

Atrius Health: Experience with global-risk contracts paves way to success in new arrangement

Case Study | Contracting

Atrius Health: Experience with global-risk contracts paves way to success in new arrangement


  • Atrius Health, a large not-for-profit, multispecialty physician group, has become the first provider organization in Massachusetts to accept full risk for a large commercial PPO population.
  • A new seven-year contract gives Atrius Health and Blue Cross Blue Shield of Massachusetts time to collaborate to make healthcare more accessible and more affordable.
  • One area in which the provider hopes to improve through the partnership is in reducing the use of low-value testing.

The trend of medical practice acquisition by health systems and private-equity firms continues to grow. But Atrius Health, the largest independent provider organization in Massachusetts, has been able to maintain autonomy by leveraging the core clinical model of managing a patient’s total medical spend while seeking new opportunities to improve the quality, access and affordability of care.

Through our new agreement with Blue Cross Blue Shield of Massachusetts (BCBSMA), we are accepting full accountability for the total cost and quality of care delivered to more than 70,000 — and counting — PPO members who are our patients. Because we have a proven record of success in global-risk contracts, and the opportunity to collaborate with this major payer to improve the care experience for our patients, we are confident that converting this patient population from fee for service to an alternative payment model will have a positive impact on patients, BCBSMA and Atrius Health.

We have been a leader in managing the total care of patients for more than 25 years. Our patients are cared for by more than 715 physicians and other primary care practitioners working in more than 50 specialties in 31 medical practices, and we provide home health and hospice services through our subsidiary, VNA Care.

Examples of our core infrastructure and patient offerings include:

  • Close clinical coordination with a chosen network of high-value hospitals, community specialists and skilled nursing facilities, based on the complementary care they provide to our patients
  • Round-the-clock telephone access to advanced primary care practitioners for patients to discuss symptoms and get advice without an unnecessary trip to the emergency department or urgent care
  • Easy and fast communication with our clinicians through our patient portal, used by more than 135,000 patients monthly, with nearly 500,000 patients registered
  • Close collaboration between clinical pharmacists, case managers, population health managers and others, ensuring proper preventive care and appropriate use of medications for chronically ill patients

New partnership advances the transition to value-based care

The processes, technology and staff engagement needed to deliver high-value care have been carefully developed over time as we have increased the number and scope of our full-risk contracts. With this new BCBSMA collaboration in place, 65% of Atrius Health’s patients are cared for under global-risk contracts, accounting for more than 80% of our annual revenue.

We are particularly excited about this new contract because, as a seven-year agreement, it gives us time to work with BCBSMA to make healthcare easier to navigate and more affordable for our patients and to work with BCBSMA’s employer-clients in new ways.

For example, patients seeking to understand their out-of-pocket responsibility before a procedure or test sometimes get different information from the health plan and the provider because at least one of the parties is working with incomplete data or the parties interpret the scenario differently. We are partnering with BCBSMA to ensure our patients can be confident that they fully understand their health benefits — and their financial responsibility — when they need the information.

Another example: Our clinical pharmacists work closely with our physicians to ensure they prescribe drugs that are both clinically appropriate and cost-effective. Going forward, they will be sharing our physicians’ perspectives with a Blue Cross pharmacy and therapeutics committee as it develops the health plan’s formularies each year. Alignment between the plan and providers will help our clinicians avoid prescribing medications that are not covered and will lower costs for all parties.

Identifying areas for improvement

We also are committed to reducing the use of low-value testing. The most recent Massachusetts Health Policy Commission report shows that Atrius Health patients had the lowest use of low-value tests and screenings in the Commonwealth and the lowest percentage of avoidable emergency department visits. Additionally, the total medical expense for our patients was among the lowest in eastern Massachusetts.

However, a study of commercially insured patients in Massachusetts, published earlier this year, found that in 2013, more than 60% of lumbar spine MRIs and about 40% of lumbar spine X-rays received in the 30 days after an initial doctor’s visit for uncomplicated low back pain were inappropriate. More than 30% of MRIs for knee and shoulder pain were inappropriate. All told, these unnecessary procedures cost millions of dollars. By combining our data with BCBSMA data to identify areas where we are not best-in-class in the appropriate use of testing, we can develop and implement protocols that improve our performance.

Mutual goals pave the way to success

Negotiating this long-term arrangement and working together to meet our goals has required a major commitment from the senior leadership of both organizations. Together, we are challenging ourselves to find meaningful and durable ways to lower the cost of care for our patients and for purchasers of healthcare coverage from BCBSMA. Our shared goals are the cornerstones of the arrangement and why we think it will succeed in the long run.

About the Authors

Patrick Holland

is CFO, Atrius Health, Auburndale, Mass.

Marci Sindell

is chief marketing officer, Atrius Health, Auburndale, Mass. (info@atriushealth.org).

Advertisements

Related Articles | Contracting

Blog | Contracting

Business Group on Health's Annual Survey: Large employers ready to take the reins on healthcare cost

Responses to the Business Group on Health's annual survey of its large employer members suggest employers are tired of waiting for providers and plans to figure out how to reduce healthcare cost.

Blog | Innovation and Disruption

Is another health plan featuring virtual PCPs as primary access point a sign of things to come?

HFMA's Chad Mulvany questions if the recent expansion of telehealth could stimulate a trend of plans offering virtual PCPs as the primary care access point.

How To | Financial Sustainability

How healthcare providers can avoid being at a disadvantage when negotiating risk contracts

Stratifying patients by risk helps finance leaders understand the cost implication differentials of shifts in utilization, giving their organizations a more solid footing in risk-based contract negotiations.

Blog | Managed Care

State legislators roll back Indiana hospital bill that could have cut payments to hospitals

Health plans seeking state legislative help with site-neutral payments will likely find allies among employers who are increasingly frustrated with healthcare costs.