The Accountable Physician Enterprise: A Powerful Tool for Success in Value-Based Care

Although risk-based contracts have been circulating for years, fee-for-service (FFS) still underpins the economics of care delivery. Payers, providers, healthcare executives, and many others keep asking the same question: when will the way we pay for care fundamentally change? The slow transition has caused many organizations to have a foot in both camps, FFS and risk-based, creating a tricky balancing act for healthcare leaders.

In this post, we will share perspectives on how physician enterprises can play a significant role in navigating this drawn-out shift in how healthcare services are reimbursed.

Growing Momentum for Value-Based Care

While the transition to value-based payment has been slower than CMS and payment experts would have liked, value-based care has been gaining momentum the last three years, for a few different reasons:

• The increase in value-based-care-specific delivery companies, such as agilon, Aledade, and ChenMed, that intend to redefine the way care is delivered and reimbursed
• Advancements in technology to enable and monitor value-based arrangements and at-risk contracts
• A rise in Medicare Advantage participation across the US, with new and out-of-the-box market entrants racing to enroll as many beneficiaries as possible in performance-based contract

To further convey the gravity of continued payment shifts, consider that CMS’s goal is for all Medicare FFS beneficiaries to be in a care relationship with accountability for quality and total cost of care by 2030.^[1] Even if that goal is not fully met, a shift to value compared to the current state will have a significant impact on the way healthcare is delivered. And as we know from years of commercial market adoption, CMS payment reforms drive the rest of the market.

A Strategic Opportunity for the Physician Enterprise

In the past, the physician enterprise has served its purpose as a tool for alignment and a driver of system utilization, even when that meant operating at a financial loss. But it has often been overlooked as a platform for health systems to enter into, and succeed in, risk-based contracts.

For many organizations, the physician enterprise starts with the primary care physicians who provide preventive and coordinated care that reduces high-cost care episodes. As patients move through the healthcare continuum, primary care is complemented by specialty providers within the physician enterprise who significantly influence care outcomes and costs.

An accountable physician enterprise moves beyond being a loss leader to attract patients and achieve downstream utilization—it repositions itself as an indispensable part of a health system’s transformation to value. This is accomplished by using all the resources of a physician enterprise, including the expertise of clinical leaders, to drive change and redesign care models to recognize the requirements of value-based care.

Physician enterprises that have been entrenched in an FFS-focused environment frequently have difficulty designing an operating model that can be successful in the value-based care environment. It requires integrating new workflows, rethinking clinic staffing, and effectively using technology to tie it all together—no small undertaking. An accountable physician enterprise has to make a concerted effort to evolve its delivery model, which we will map out with the key levers for the operating and economic model.

Transition to Risk-Based Contracts

Transitioning from the incentives and expectations of an FFS model to value-based contracts requires planning and preparation in three critical areas: provider compensation, value-based care operations, and managed care contracting. Although the remainder of this post focuses on value-based care operations, which is at the center of care delivery redesign, a full and successful transition to value requires all three areas be working together, with leaders aligned on a common purpose and guiding strategy.

Operating and Economic Model: Key Levers

Under a value-based model, ambulatory operations must be prepared to transition from episodic care to population health management. This transition will rely on:

• Enhanced capabilities supported by new and improved workflows that consider value.
• More robust support staff models with refined roles and responsibilities.
• Fully integrated and optimized IT, EHR, and analytical tools.

Workflows That Consider Value

Clinic workflows have historically focused on facilitating and capturing reimbursement for an efficient patient encounter, but this model will not suffice in a value-based care environment, where there are new incentives and expectations for the clinic. Workflow design and priorities must be aligned with the specific incentives of each organization’s value-based arrangements. These revamped workflows can include categories such as:

• New clinical tasks and actions (including documentation), which magnify wraparound care that focuses on the whole patient.
• Additional clinical monitoring, allowing providers to monitor patients’ health and care plan adherence outside of their infrequent office visits.
• Patient and care team communication requirements that serve as a tool to activate patients in their care and keep them healthy.

Staffing Infrastructure

Under value-based models, ambulatory providers and their teams are expected to support a broader range of activities. Alternative care team models will require reassignment of staff resources and deployment of net-new resources to support incremental work, such as care gap closures and patient navigation.

Whether to deploy these resources depends on the organization’s maturity within value-based arrangements and the proportion of the business these arrangements support. Models typically fall within a continuum, from fully centralized to fully decentralized. Overall, the role of support staff tends to be elevated, and team-based care concepts become more important to support value-based arrangements. New roles include but are not limited to:

• Health coaches.
• Care coordination team members.
• Panel management coordinators.
• Ambulatory pharmacists.
• Behavioral health professionals.

Optimized IT, EHR, and Analytical Tools

As an organization transitions to value-based care, the importance of capturing and storing patient information and having actionable data at the clinicians’ fingertips will expand, because clinicians will now be at risk for their patients’ health outcomes. To remain efficient/viable, data capture must become increasingly automated, the information itself must be easy for providers and care teams to access, and the output of AI/BI and other analytical tools must be readily available at the right time to the right person to take the right action.

While the EHR will continue to reside at the core of the data operation, additional applications are often required to improve or achieve:

• Risk scoring and stratification.
• Care management and coordination.
• Patient engagement (to drive patients’ participation in their care).
• Automation of performance-based activities (auto-scheduling a specialty referral) and when to use the EHR or a third-party product.
• Predictive analytics.

A physician enterprise that takes these steps to operate as an accountable physician enterprise will become the key mechanism for a health system’s transformation to value and ability to win in risk-based contracts.

What’s Next?

Now that we have laid out the foundation of why the accountable physician enterprise can be a powerful tool in a successful value-based care model, subsequent posts will discuss the key components of workflows, staffing, and optimized IT, EHR, and analytical tools in greater detail.

_{Edited by: Matt Maslin, Jay Santini}

Published March 22, 2023