What’s in Your Clinical Integration Playbook? Tips for Fruitful Value-Based Models

With a new administration, one question we continue to hear from providers is – should we expect more risk or will the push toward value stall out?

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With a new administration, one question we continue to hear from providers is – should we expect more risk or will the push toward value stall out?

CMS administrator Seema Verma began to clarify the response to this question when she stated that the Center for Medicare & Medicaid Innovation models that yield the most quality and cost benefits are those with providers taking on more risk. Verma’s guidance means the status quo isn’t an option. CMS is expected to build upon these lessons learned from top performers by expanding value-based programs with increased levels of provider risk.

Movement in this direction will not be easy.

  • Significant investments are required to bring payer-like capabilities to providers.
  • Spend targets don’t often reflect the true complexity of the population under management.
  • Payer partnerships aren’t always mutually beneficial – providers often must decrease their revenue to perform well, which only represents a fraction of their book of business.

The question then becomes: how do providers create meaningful payer relationships and ensure flaws in value-based payment design don’t harm them in the transition to assuming higher degrees of risk?

1. Improve the quality of care and bend the cost curve with value-based models

During Session 3 of Guidehouse’s 2020 Clinical Integration Summit, executives from a health plan and an accountable care organization (ACO) shared key insights for healthcare leaders in developing fruitful payer-provider partnerships, and ensuring accurate coding and documentation to enhance performance.

“Providers are being pushed to take on more risk, and they are investing a lot of capabilities to be successful at that,” said Brett Erhardt, vice president, Corporate Strategy at Bright Health Plan – a health plan with a presence in 34 markets across 13 states, $1.2 billion in annual revenue, and industry-leading medical cost ratio performance.

2. Choose a partner that augments your organization’s value capabilities

Bright Health looks at their provider partnerships from a macro perspective, focusing on what they need to do as a payer to ensure their provider partners have everything they need to successfully manage their patient populations. Such capabilities include not just the technology and tools to engage members, but also the infrastructure for population health management, from access to data to advanced analytics.

“We've got brand-new benefit products that allow consumers to have choice, enable us to have enough mortar in a particular market, and most importantly, allow us to get to a high enough percentage of wallet share for providers to be successful,” Erhardt said.

Bright Health partners closely with a narrow set of providers that they can deeply align with financially, clinically, and from a technology standpoint in their local markets. This helps them drive high in-network usage rates. Also critical to success: a contracting strategy that stretches across multiple lines of business, a willingness to contract in innovative ways, and a large enough network to support integrated care.

3. Explore multiple opportunities to drive value

“There are many opportunities to succeed well under value-based care. So, you might want to look at opportunities you haven’t thought about,” said Martin Serota, MD, chief medical officer, Bright Health Care (BHC), the care delivery arm of Bright Health.

For example, BHC collaborates with providers to develop a clinical integration playbook based on the health system’s priorities and appetite for risk, with a focus on unique opportunities for value. Then, BHC assesses the health system’s strengths and weaknesses and assists leaders in building out their primary and specialty care networks.

“You can move along the risk continuum at your own comfort level and then demonstrate that you can manage that risk through improved quality scores and lower costs,” Dr. Serota said. “When you are in the market driving lower cost and higher quality, you and your health plan partner will have a competitive advantage.”

Both Bright Health Plan and BHC also establish a joint model for clinical governance to secure physician and clinician alignment. That’s an area where providers tend to struggle.

Health system investments in physician engagement are needed to support payer-provider collaboration and accept higher levels of risk. Two-in-three healthcare leader attendees during the Clinical Integration Summit said securing physician engagement is a bigger challenge than securing member engagement.

4. Proactively manage your population—especially during the pandemic

“We have an obligation to get out into the community and make sure we’re addressing whatever chronic conditions our patients are presenting,” said Ren Mullinix, vice president, Risk Adjustment and Coding for Southwestern Health Resources (SWHR), a clinically integrated network with 29 hospital locations and nearly 5,000 physicians and advanced practice providers.

Nearly 30% of Clinical Integration Summit attendees said they plan to increase investments around member engagement as they prepare for value-based payment. For example, during the pandemic, SWHR has used claims and electronic medical record data to identify “COVID-19 hotspots”.

With this information in hand, SWHR works with providers to educate vulnerable populations on ways to reduce their risk of infection. It also enables clinical leaders to provide individualized support to patients that live in these areas based on their medical history. This not only ensures continuity of care during the public health crisis, but also helps dissuade members from putting off needed care.

5. Strengthen risk-adjusted coding capabilities

“To the extent that we can manage disease burden and shrink costs, that's fantastic. But if we're not accurately capturing the disease burden—if we’re not monetizing the actual work we're doing—then the margin is deteriorated,” Mullinix said. “That’s where risk adjustment comes in.”

The success of SWHR’s ACO, ranked No. 1 in the U.S. for cost savings and quality performance, is due not only to its high-functioning medical management capability but also its ability to document hierarchal condition categories (HCCs) to calculate risk scores.

SWHR’s evolution as a leader in clinical documentation did not happen overnight. “It’s been a systemic, judicious, and thoughtful process,” Mullinix said.

SWHR leaders created a playbook for clinical documentation in 2019, with an emphasis on preservice review. At that time, the organization struggled with underdeveloped management tools, analytics, and business intelligence. As SWHR invested in the tools to strengthen clinical documentation, leaders also contracted with advanced care practitioners to conduct in-home risk assessments. The member risk profiles that result from these assessments help clinicians and coders better capture the complexity of the patient population.

“The ability to which an organization can accurately and specifically document chronic conditions translates to precision in reimbursement,” Mullinix said. “We’re then able to reinvest these dollars back into population health through care management, network efficiency, quality analytics, and more.”

6. Let innovation drive value

Finding the right pathways to success under value-based payment models isn’t easy, but it’s possible with innovative strategies in place. Payer-provider collaboration and proper clinical documentation play vital roles in positioning healthcare organizations for sustainable success.

For more insights from Session 3 of the 2020 Clinical Integration Summit, watch select on-demand recordings.

You may also be interested in recaps of Sessions 1 & 2:

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