On today’s episode, join us as we dive into the world of Value Based trends in primary care markets with guests Mike Scribner, John Crew, and Kelly Mooney. They share their expertise and discuss how independent PCPs will be impacted by these trends in healthcare. They will highlight both Commercial and Medicare arrangements in the marketplace, how practices are impacted by such, as well as how best to thrive and incorporate into an overall managed care strategy.
Guest: John Crew, Principle & Founder, SHP LLC
Principal and Co-Founder of SHP, John W. Crew is a graduate of Valdosta State University and has over 25 years of experience in healthcare. He is experienced in ACO formation and management, IPA/PHO formation and management, managed care, and development of ancillary revenue streams.
John resides in Athens, GA (Home of the back to back college football national champions) with his beautiful wife Vickie. They have 2 sons that are now out conquering the world.
You can reach him @ jcrew@shpllc.com or (912) 691-5711.
Guest: Mike Scribner, Principle & Founder, SHP LLC
Mike Scribner is the Principal of Strategic Healthcare Partners (SHP), based in Savannah, GA. He has an extensive background in managed care contracting, revenue cycle, CFO support, budget development, decision support, and growth strategy development. He holds a Master’s in Accounting from the University of Mississippi and is a member of HFMA and NAHU.
Mike began his career at Ernst & Young in Memphis, Tennessee. He later served as the Director of Finance at LeBonheur Children’s Medical Center, then Director of Managed Care for its parent organization, Methodist Health System. Mike moved to Savannah, Georgia in 1996 to become CFO for CareOne Home Health at Memorial Health University Medical Center. During his tenure with Memorial Health System, Mike served in capacities of Vice President of Finance/Administrator-Corporate Finance, then Vice President of Managed Care/Homecare for the Health System.
Mike left Memorial in 2004 and launched a managed care consulting firm called Health Resources Group. In December of 2008, HRG and Preferred Healthcare Consultant (PHC) combined to form Strategic Healthcare Partners (SHP), which now has offices in Villa Rica in the
Atlanta area and Savannah.
Guest: Kelly Mooney, VP of Managed Care, SHP LLC
Kelly Mooney is the Vice-President of Managed Care for Strategic Healthcare Partners, LLC. Originally from Wilmington, Delaware and a graduate of North Carolina State University, Kelly has spent the last 20+ years serving healthcare clients in Georgia.
In her time with Strategic Healthcare Partners, Kelly has specialized in IPA/PHO formation and management, managed care strategy and negotiation and value based models. SHP works to support all providers with the guidance and management to navigate the business of medicine; often functioning as an extension of their business office.
In addition to ‘traditional’ providers, SHP has unique expertise in addressing the needs of rural healthcare providers, who are routinely underserved in access to the services that SHP provides.
Transcript
Aaron Higgins:
Welcome to Beyond the Stethoscope Vital Conversations with SHP. While we’re on our break preparing for the next season, we’re revisiting some of our most insightful episodes to keep you informed. In this replay all the way back from Season 2, we dive into the evolving landscape of value-based care in the primary care market with industry experts and SHP founders Mike Scribner and John Crew. We’re also joined by value-based care expert Kelly Mooney. In this episode, our experts break down the latest trends that are shaping the future of primary care, exploring how independent practices are being impacted by commercial and Medicare arrangements. Independent practices are being impacted by commercial and Medicare arrangements. They discuss the challenges and opportunities that these changes bring and share strategies that can help practices not just survive but to thrive with an overall managed care framework. So, whether you’re a provider navigating the complexities of value-based care or simply curious about the future of healthcare, this episode is packed with insights that remain as relevant today as they were when we first aired it. Stay tuned while we revisit this vital conversation to help you stay ahead of the curve.
Mike Scribner:
So, as an opening question, you guys let’s talk about what trends in value-based care you’ve seen, kind of start high level and kind of tell me what value-based trends you see are out there and what opportunities you think that primary care in particular may be encountering.
John Crew:
Well, I’ll jump in. This is John Prude, I think, and Kelly can certainly add to this, I think. When you think about trends, I think you really talk about the sort of the evolution of value-based care in general in other states. Historically speaking, when we have value-based care, they tend to gravitate into the larger metropolitan areas, because it’s all about attribution, everything’s about attribution. So they’re looking at what’s my fastest way to get a significant number of patients, and so if you can go into an Atlanta or an Augusta or Savannah where you can pick up 20,000 attributed lives with four or five groups, that sort of becomes your target market.
John Crew:
And so the consequence of that is is that particularly rural providers, who don’t have that kind of volume, they tend to get left out.
John Crew:
It’s not just that they’re left out, they’re just those opportunities don’t exist for them.
John Crew:
And so what we do here at SHP is we’re trying our best to figure out how to incorporate those practices and give them opportunities that otherwise they wouldn’t have, and part of that is by being able to coalesce them together where their combined attribution becomes the same meaningful attribution as a couple of large practices in the metropolitan areas, and I think that there aren’t a lot of people out there doing that, and I think that’s what makes us a little bit unique at SHP out there doing that, and I think that’s what makes us a little bit unique at SHP. Have you thought about how to coalesce and work collectively with the rural providers? Part of that build is going to take place because there’s going to be a bit of a blueprint that’s going to come from Medicaid. As Medicaid moves into value-based care, they’re going to have to bring value-based care into the rural markets. So we may have part of that blueprint moving forward that we’ll be able to go back and share with the other payers in the marketplace.
Mike Scribner:
Describe to us the types of models that have evolved in the market from a Medicare Advantage perspective have kind of come first, but I guess commercial came first and now Medicare Advantage is kind of coming into the market. Give us some description of the most prevalent two or three, four models that are out there.
Kelly Mooney:
So the most common model, I would say that has the largest footprint from a Medicare Advantage standpoint, is going to be Humana’s model practice engagement. The key component of that continues to be quality driven Primary care practices, probably very familiar with HEDIS quality metrics A1Cs that are being done. Are you closing your care gaps for screenings, for colonoscopy, breast cancer screenings, all of those different studies and tying quality and financial incentives to meeting those metrics for your population, keeping them out of the emergency room? The other component that we’ve seen tie in more to that is, upside shared savings models. Shared savings models. Now, the challenge on that side has been particularly in rural areas. To John’s point, aggregating enough of a footprint to move any financial metrics continues to be a challenge and with smaller populations of providers within communities it becomes more difficult to redirect care in those settings.
Mike Scribner:
I guess, medicare aside, what’s the most prevalent commercial model out there and how does it differ?
Kelly Mooney:
The only real model that’s out there today is Anthem’s enhanced personal health care model and it is tied to again an attribution model based on who is delivering the most primary care to a particular patient, similar HEDIS metrics keeping people out of the emergency room, doing your transitional care, management, monitoring medications for your patients and there’s also a financial component that has been even more challenging to hit than the Medicare Advantage side has been.
Mike Scribner:
Before we start talking about sort of operational issues with being successful in those programs, which is where I want to hit. How does a typical primary care practice get involved in one of those programs in the first place? How are they accessed in the first place?
John Crew:
They’re recruited. I mean, if you really go back to the inception of Value Base, it really was the original MSSP plans and so everybody recruited primary care into that. And unfortunately, because CMS’s original model has evolved dramatically which is the good part unfortunately because in the early stages a lot of those MSSPs failed and so it was only after CMS sort of adjusted and Kelly talked more to this, but it’s only after they adjusted did physicians become to be successful. But at the end of the day they were recruited. And I will go back again to repeat Kelly, they’re recruited based on their attribution they’re looking at. Originally, you know, in the MSSPs they needed 5,000 lives and over the course of time they’ve discovered that the higher the attribution, the less risk there is for losing money. So now most people went to 10 and 15 and now really a top number is 20,000. That’s sort of what people are looking for. And so even though the red, white and blue population is declining and there’s more and more of it, that’s going into the MA plans and that’s what’s bringing more of the MA life, there’s still opportunity within the traditional red, white and blue. But because they have to be recruited, I’m going to go back to what I said in the beginning. It’s been to this point.
John Crew:
It has been our organization, shp, which has brought those lives up into partnering with ACOs, whether it be the red, white, blue or the MAs, and we do have at least one red, white, blue ACO that we brought the vendor in and we put them together with the physicians. That has been incredibly successful. And then on the commercial side, I know Kelly mentioned that the Blues DPHC program was the most prevalent, then Humanis program. I think they all have some model but unfortunately, at least to this date on the commercial side, I don’t know that they have been at least with our client bases. They have been incredibly successful is because I think and I would really like to hear Kelly comment on this I think part of that is the payers are being forced to implement standardized models that may be universal across state to state and they’re very claims-based driven versus clinically driven, and so I think that’s had a bit of a negative impact. That’s why the MSSP has been successful, because you get real-time data or close to real-time data. That’s actionable. Kelly, you have any thoughts?
Kelly Mooney:
Yeah, that’s a great point, John. The challenge to accessible and actionable data is the biggest hurdle in any of the non-traditional Medicare models. Obviously, there’s always a delay because claims filing is going to run behind for all health care providers, but there’s been a real difficulty for all of the payer partners that we’ve worked with the market and there are limitations to what you can do about their downstream contracts, how material the financial returns can be.
Mike Scribner:
Is this worth the squeeze in terms of whatever operational changes we’re going to talk about?
John Crew:
It can vary. I think there’s a risk reward. I think the reward that we are most familiar with has been what our clients have done, and we have clients that have done incredibly well in it. Financially it has meant a significant amount to their practices and that’s through accumulation of an MSSP on the commercial side the EPHC that Kelly spoke about. You know their relationships with other payers, including Medicaid. All of those combined they have been very successful. Their practice flows within the practice but for the most part, I think they would tell you that they are still practicing medicine the way they always practice medicine. I think what they would tell you that has been the real benefit to them is they understand coding better. They understand the coding to acuity better. They understand the impact of not doing that, not doing that, I think they understand, of closing gaps, of really managing your bottom 5%, which is driving about 80% of your costs. I think they would tell you that, but I don’t think that. I think what they would also tell you is that their imaginary thought of what that was going to be, the requirements as far as staffing changes, all of those things. I think they would tell you that it wasn’t as severe as they thought it was going to be. But the real challenge in this too, michael, is that I think we have to recognize that what I was saying earlier about these value-based models haven’t been available in the rural communities. And as these companies continue to come into Georgia now you’re getting some saturation out of Atlanta, a little bit of saturation out of the other MSAs, and so you’re really getting down to the rural market, becomes a little, can become a little bit of a target market, particularly, say, for a boy crossing their EPHC, things like this.
John Crew:
But what is happening is everybody. There’s two factors. Happening is everybody. There’s two factors. One is everybody is pushing to go at risk because the risk is where the greatest reward is for the money. The more risk you take on the traditional red, white and blue, the better the opportunities. If you take the full risk, you no longer have to split with cms 50 50. You can split at 75 25. There are different within there. So there’s a big push to do risk.
John Crew:
And then on the MA side there’s a big push to get to capitation and these things in and of themselves can be a little frightening. But the fact is these models have proven to be successful. But to go from doing nothing to capitation or from nothing to be at a financial risk is, I think, has unintended consequences and I think that’s why, for our clients, we have tried to work with them, to match them with the right partners where they won’t be at any kind of financial risk or harm to their practice. And value-based medicine is an opportunity to augment that revenue but not to replace fee-for-service and I think you have to have that mindset.
Mike Scribner:
So, again, keeping on kind of dropping this down another level. What are and I guess I’ll direct this at you, kelly what are the sort of two, three, four items that have driven practices to be successful in either an ACO model or the Medicare Advantage plans that are prevalent in the market?
Kelly Mooney:
So I think the initial driver is physician commitment to the model and situating their practice for success. Part of that is working a care coordination function within their practices. John, anything to add?
John Crew:
Yeah, I think that it really is models that have been driven by the providers themselves, as opposed to having someone come in and tell them what to do.
John Crew:
I think the models have been successful. Their partners have provided data and resources. I think it’s been on the physicians themselves to collaborate with each other and hold each other accountable. And really I’ve been in some fascinating meetings with physicians and I’m not a clinician, but I’ve been in some fascinating physicians where physicians are talking to each other about why you use one code versus another code and what that means, and why you use this modifier versus this modifier, because this is what it means in terms of acuity or cost or all of these things. And I think the education that wasn’t insurmountable, but it was an education. And I think once folks learned that, they really began to understand the importance of really making sure that and I can’t overstate this to making sure that they were capturing the right acuity and doing the right coding, and those things in and of itself and, kelly, you comment on this those things in and of itself are probably about 80% of the lift.
Mike Scribner:
So explain that a little further for the regular person in the audience here. Why is coding so important that it’s tied to the financial return? How to connect those dots.
Kelly Mooney:
For particularly traditional Medicare and Medicare Advantage, the funding that goes into the financial model. What they’re going to base your financial return off of, is based on patient acuity, and that’s captured through something we call risk adjustment. That are the diagnosis codes that are submitted on claims, those reset annually. So even for conditions that would never change say, one of the highest risk adjusted codes, if you’re HIV or AIDS positive, that’s going to drop off at the beginning of every year, even though in today’s clinical world that condition will never change. So making sure that you’re capturing how sick and the actual acuity of your patients are every year means that the plan is appropriately funded for the care that that patient is expected to receive. And so that’s the key component you can be much more impactful on the funding than managing downstream cost. You will never lose back dollars that you didn’t capture by miscoding your patient, because their costs are going to be the same. You just weren’t funded for that care.
John Crew:
And as a lay person, Michael, what that means to me is that if you don’t capture those codes, you’re still treating those codes, but you’re only targeted for what you’re treating for that time to CMS that looks like that you’re out of line with your care, that you’re giving the cost for your care Because while you’re treating that, you would have been by not coding it and going back and picking up all of those things that follow. I always think of heart attacks. People have had heart attacks. By not keeping those things going, it looks like your patients are sick when they’re, not when they’re in actuality.
Mike Scribner:
All right. So shifting down to OK, I see the, I see the benefit, I see the sort of the key drivers that have driven success. Talk about the con for just a second. What? What operational concerns? Practice throughput, disruption. Have we seen kelly, you and john, have you all seen in practices that have gone in the deep end and adopted sort of a full model along these lines?
John Crew:
hardest thing is there. There are people that get it, and then there are people that don’t get it, that are willing to change. There are people that are willing to understand the importance of coding and why I need to code that way and they’re willing to adopt it and do it and move forward. And then, unfortunately, there are providers in these groups. They got in just to see if they got a check, for no other reason. They’re not committed, they’re just I want to get in just to see if I get a check. And so once your data starts coming out, it’s going to tell you I mean, it is absolutely going to tell you these are the folks that are killing it and doing the right thing and these are the folks that aren’t.
John Crew:
The first thing you’re going to do is go to those that aren’t and you’re going to try to bring them up to the level that the others that are. I mean to the level that the others that are. I mean you’re going to. It’s going to be peer-to-peer conversations about. Here are the things you need to do to be successful, because if you’re not successful, you are negatively impacting me, you’re affecting my money. So the goal is to do that and at the end of the day. If you have those that just absolutely never buy in at the end of the day, the downside is they’re going to kick them out.
Mike Scribner:
But at a throughput perspective and I guess, kelly, this one’s to you too. What’s the feedback that we’ve been on a practice’s ability to not disrupt the regular throughput of patients? As, john, as you alluded to before, we’re a fee-for-service state, we’re paid per click. Is our experience that implementing effective care coordination and and vbc supportive activities in the practice has it slowed down the practice? What are the sort of the disruptive things that a practice needs to be aware of as they go through this? I’m talking pretty low level, operationally.
Kelly Mooney:
I don’t think that we’ve seen that level of concern from the practices that have integrated value-based care models. The biggest sort of disruption that we’ve seen is really on the lower-level staff in the practice in terms of identifying and targeting in their own EMR who’s tied to what model, what care gaps they need to close. So that’s where we’ve seen more of the operational work done.
John Crew:
I will say and Kelly can add to this one of the things, mike, that it’s important when you’re trying to identify the right partner assuming you don’t want to do this on your own when you’re trying to identify the right partner, I think the most critical conversation and this is indicative of whether it’s Medicare Advantage, medicaid, commercial, any other it’s really what resources is your partner putting out there? Are they boots on the ground? Are they sending coders out? Are they getting people in the market out there with you to help close those care gaps? Are they making outbound calls to patients to get them in or they helping verify that?
John Crew:
You know, if you’re diabetic, you’re supposed to have a, supposed to have an eye exam and they’re not being dependent on hoping the eye doctor sends notes back to the primary care. They’re out there tracking that down. It’s really what are they doing because, remember, most of these partners are getting, you know, at least half of these savings. So the tools that you need to be successful that’s the pot it needs to come out of they need to reinvest in the market and the more successful they are as a group, the more you want your partner reinvesting in the market and resources to help you achieve those success, as opposed to it all being solely dependent on your practice.
Mike Scribner:
John kind of concluding point to kind of wrap this back up and get kind of back to the high level. What would our general recommendation be? I’m a five doctor primary care practice in Vidalia, georgia, independent. I really haven’t stuck my toe in the water of this at all. What do I do next? What do I do first?
John Crew:
I think we you know, for us, you know, if there are clients, we’re and this is something they want to do that the thing we want to do is we want to try to identify the right partners and we’ve got some working relationships. You want to identify some partners out there that you can collaborate with to bring them in at a zero risk to the practices. And so what a lot of ACOs have started doing is they have started building now multiple ACOs started doing is they have started building now multiple ACOs, and so what they’ll do is they’ll have one that they put everybody in and it’s sort of the learning curve ACO, and it’s where you learn how to interact, get data, give data and how successful you can be. And then, if you’re really successful, what they tend to do is they gravitate you up to an ACO that has been in existence and has made really good money, so they see you as a contributor that’s going to enhance that one, and so they move you up into another ACO. And for the others, they continue to try to train and help and bring along, but at no risk.
John Crew:
But it’s really sort of like you know, it’s sort of like getting value-based care 101, you sort of it’s sort of like getting value-based care 101, but you’re at zero risk, you can’t fail, you just may not, can pass, and so the reality of it is is that’s sort of the models that we’re trying to find out there and look for Same thing on the MA side of it. We want to find partners that don’t require you to go directly to capitation. We want to find partners that are going to work with you, continue to work with you where there’s upside dollars in this, build the same models. Having those tiered models is a key, because when you’ve got a model that’s incredibly successful, then it’s your goal to try to get from the A tier to the B tier, because the money’s already in the B?
John Crew:
tier. You don’t have to it’s already there.
John Crew:
You’re just going to add to that. So it’s getting people that want to put those tiered models in to help them come through. And as you get into the upper models that are doing incredibly well, you do want to go to capitation. You absolutely want to take risks because you’re going to kill it. You, you, you’ve been doing it, you’re going to continue to do it, but that learning curve you don’t want to be in any position to take any risk at all. Is that a fair statement, kelly?
Mike Scribner:
It is John.
Aaron Higgins:
Okay, well, thank you all for your time today.
Jason Crosby:
You’ve been listening to Beyond the Stethoscope Vital Conversations with SHP, a production of Strategic Healthcare Partners. For more information about our podcast, including back episodes, show notes, transcripts and more, visit our website at shplccom slash podcasts.
Aaron Higgins:
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Jason Crosby:
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Aaron Higgins:
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Jason Crosby:
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Jason Crosby:
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Jason Crosby:
And, as always, thank you for listening and have a great, wonderful day.