Infrastructure, Staffing and Culture Work Together to Navigate Risk

By Sanjay Seth, MD, Executive Vice President, HealthEC
Twitter: @HealthEC_LLC

Medical staff members are often the last to be informed of new risk-based contracts. However, they are usually the first to feel the financial impact of taking on greater risk. With our nation’s medical staff leaders and professionals in mind, I recently coauthored an article for the March 2020 issue of Medical Staff Briefing (MSB) in collaboration with Cliff Frank, interim executive director at Shore Quality Partners in Somers Point, New Jersey.

In the article, we highlight the importance of solid technology infrastructure, proper support staffing, and physician culture in an organization’s ability to succeed in CMS’s new Pathways to Success program. Tough conversations are necessary. Difficult investment decisions will be required. In particular, the following three points are important for healthcare providers to keep in mind as they journey into new accountable care models.

Start smart: Analyze your data to better inform new performance track decisions. Consider all factors: track options, risk level, entry point, experience, revenue, benchmark changes, assignment changes, attribution methodology changes, and agreement length.

Assess operations and infrastructure: Evaluate your staffing and community partnerships to determine where more capabilities may be needed. From a technology infrastructure perspective, ensure your platform can provide lists of at-risk patients for more active health discussions or care coordination.

Engage medical staff and executives in active discussions: Data transparency is critical for this step. Strive to identify top and bottom performers in risk-based contracts and share information to motivate better clinical performance.

Build a culture of inclusion: Physician culture plays a tremendous role in achieving success. We recommend medical staff leaders pay particular attention to the following five areas when engaging physicians in risk-based conversations.

  1. Educate physicians on the high cost of patient leakage
  2. Focus referrals to high-performing specialists
  3. Meet the basics: patient wellness, prevention, immunizations, etc.
  4. Build patient engagement efforts to keep small health issues small
  5. Take direct, limited financial risk

Line up funding options: Some organizations may need to write checks back to Medicare. Have frank conversations about downside risk and investigate your funding options. Here are six worth noting.

  1. PCP membership fees
  2. Net collections from reinsurance
  3. Medicare Advantage (MA) star bonus program
  4. Previous year bonus carryover
  5. Bonus deductions
  6. Hospital/investor line of credit

Participation in CMS’s Pathways to Success program requires an intentional approach to address those topics with physicians and drive organizational improvement. We propose four keys to success: understand your performance track options and requirements, ensure physician buy-in, establish funding, and mitigate risk through data-driven decisions.

This article was originally published on HealthEC and is republished here with permission.