Nephrologists need to be at the top of their game in value-based care partnerships
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Small-and mid-sized health care practices, like mine, are increasingly interested in adopting value-based care models.
Much of the appeal of value-based care is the flexibility the model provides to take better care of our patients. But a number of external factors are also leading us down this road, including fee-for-service payments lagging behind costs and looming deadlines, such as the CMS goal of having all traditional Medicare patients in an accountable care relationship by 2030.
Participating in value-based care contracts is becoming necessary for the survival of many practices. I have participated in value-based contracts with my nephrology practice in Raleigh, North Carolina, for 6 years. In that time, I have experienced the varying opportunities and challenges offered by the different pathways to value-based care.
Overhauling how your practice operates and generates revenue is no small matter. The financial risk that value-based contracts put into a practice can threaten the success of the business. That is why small- and mid-sized practices often partner with external value-based care support partners to make the transition.
Develop a plan
Not all care management providers are created equally, nor are the best practices, tools, autonomy, risk management and revenue-sharing these offer. If you are vetting potential partners, following are four items I encourage you to consider:
Know thyself – Knowing yourself, your practice partners and your business are essential when considering a value-based care partnership. You must deeply understand your circumstances before you can assess the potential fit of a value-based care collaborator.
Patient mix – What is your current patient mix and how will that impact the ability of your practice to participate in specific value-based care arrangements? Value-based agreements can come with different patient attribution requirements that may or may not align with your current payer mix. You need to understand how patient attribution works in various value-based care arrangements to understand the impact participation will have on your practice.
Baseline costs – What is your current baseline cost and how has it, or will it, change over time? Again, value-based contracts come with expectations, including target costs, which can be tied to episodes of care, individuals or entire populations. Only by knowing your current reality can you begin to consider if you will be able to successfully meet the terms of the agreement now and as these may evolve over the contract.
Risk tolerance – What is your risk tolerance and that of your partners? As with many things, the path to greater rewards is often through greater risk. My practice partners with a group that sets patient outcome goals that look further into the future — we share in more of the risk and, therefore, more of the profit. The most common alternative is a “retrospective” model that tends to simply look backward at saved costs. This effectively is fee-for-service care in disguise and lacks the same potential upside for the provider and the patient.
Understanding the tremendous value of data — and how to efficiently access that data — underpins any successful value-based care model. Immediately, there should be education for the physicians, nurses and other staff in your practice. Be sure to understand the level of hand-in-hand orientation a potential value-based care partner offers. Everyone needs to quickly become comfortable with new systems and processes, particularly how to get to and utilize data that will be available to them.
Moving forward, value-based care partners should provide this data in a digestible, actionable format, so a provider can efficiently make meaningful changes to their care practices. Data should include up-to-date attribution lists, inpatient and outpatient costs, quality metrics and callouts of small patient groups that need closer attention because of current or potential future costs.
Data support could also include an intuitive electronic health record system that supports gathering the correct data now and seamlessly offering up timely screenings, patient comorbidities, and even performance benchmarks.
At the center
The most successful and happiest value-based care partnerships are the ones where you, the physician, are at the center. That means finding a partner that is willing to support and adapt to your processes, not simply impose their own.
For example, many value-based care partners promise a litany of support, but it is often provided to patients outside your view. This can range from nutritionists offering clinically sound advice that is different enough from your own to cause confusion for the patient to a pharmacist adjusting prescriptions you carefully calibrated without consultation.
This causes confusion and work for your patients, makes your job more difficult, and sows seeds of distrust between you and your patient. If you are meant to be the lead of a patient’s accountable care relationship, you should be front and center in all care.
Care coordination
Care coordinators are the backbone of any successful value-based care agreement. Care coordinators make all the difference, helping patients navigate our complicated health care system and matching them with the support they need throughout their journey. If a value-based care management provider is not offering to aid you with this critical piece — and in a way that truly coordinates with you — look elsewhere.
I can tell patients that their eGFR is 20 mL/gL2 and that they need to have an arterio-venous fistula placed. After the visit, I can click a button to have an administrator schedule the procedure for that patient.
But if you have practiced medicine for some time, you know this does not guarantee the patient follows through, which then slows down future care and can lead to a preventable visit to the hospital.
For me, care coordination has worked best when the coordinator is embedded in my practice. Over time, my day-to-day collaboration with the care coordinator has become an essential part of how I deliver care to patients. While an in-person coordinator may not always be possible, be sure you are able to reach, and work with, the coordinator as readily as your patients can.
Partners key
At the end of the day, the right value-based care partners need to be true partners to your patients and your practice. They bring tremendous value that can improve care and service, and reduce waste and cost. But small- and mid-sized health care providers are best when they maintain their flexible focus on serving the needs of their community rather than being overridden by an outside entity. Be in constant communication and watch for indications your partner might be working over or around you, especially if they require you to be exclusive to their network. Do not be afraid to advocate for yourself as an expert clinician who understands the needs of your patients.
Finding the right partner to help provide value-based care can take significant time, attention and energy. But that investment in finding the right fit can pay tremendous dividends to your patients and your practice.
- For more information:
- Michael J. Casey, MD, is a nephrologist and practice leader for North Carolina Nephrology, PA, in Raleigh, North Carolina. He can be reached at mcasey@ncnephrology.com.
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