Embracing risk to succeed in value-based care

Andrea Hurteau, chief operating officer, Boncura Health Solutions, started her work in healthcare on the clinical side more than 20 years ago but soon was intrigued by managed care and how business intersects with the clinical side.

Since moving to the administrative side, she has bounced from the provider side to the payer side, “watching how risk plays out on both ends,” she said in a recent interview for the MGMA Insights podcast. “There’s been a significant evolution in providers bearing risk … but some of the same core issues still exist today” amid the shift to value-based care.

The biggest risks in shifting to value

Hurteau said that taking on risk from a provider perspective requires transformation. “You can’t expect to do things the same way you did in a fee-for-service world and truly deliver value or be successful,” she said, noting it requires “a strategic change within the organization, as well as a realignment of resources, infrastructures, partnerships and overall provider engagement in order to be successful.

“The risk lies in the ability of the organization to transform. And they're required to have payer contract transformation, obviously care transformation and, most importantly, data transformation,” she said.

The role of data

In a fee-for-service world, providers are not as engaged in the downstream claim payment or the overall cost of care that a population has on a payers’ membership, Hurteau said. Moving into value-based care, providers need to be more engaged in the overall cost of care for a population, including insight into care that a provider who's engaged in a risk model is not providing for their membership.

“We're seeing a transformation to downside risk and encouragement from payers [for providers] to take this on,” Hurteau said. “And often, a lot of this expense or differential in outcome happens outside of a provider’s own system, and therefore data provides insight to the provider taking on risk on what's happening outside of their world. That's a very significant change from what we've seen in a historic fee-for-service environment.”

Locating risk via analysis

Embracing the need for data and analysis in the move to value-based care “will tell us where the risk actually lies,” Hurteau said. “What areas can we do something to improve the overall cost and quality of care? Once we've identified what's actionable, then you need to come up with a plan on how to address that potential opportunity within a risk-sharing arrangement. And finally, once you come up with a plan, you need to continuously evaluate, is your plan working?”

Hurteau says the evaluation piece is where some medical groups have difficulty: They might have a plan in place, but then the feedback needed for potential future interventions is not generated.

What success looks like

Hurteau pointed to the example of DuPage Medical Group, a large, multispecialty physician group that took on provider risk with a significant Medicare Advantage population. “You certainly have to be cognizant of strategic interventions to manage your most costly and most susceptible patient base,” Hurteau said, noting the costs of patients with comorbid chronic conditions and social determinants of health factors “impacting their ability to seek care and be compliant with their care.”

Through data analytics, DuPage could identify who those patients are that have above-average utilization and even avoidable utilization, such as unnecessary emergency department visits. The next step is to “create a strong primary care relationship with a targeted subset of a patient population that you’re at risk for,” Hurteau said. In DuPage Medical Group’s case, that meant creating a Breakthrough Care Center clinic model to serve the highest-risk patients within their Medicare Advantage risk population. The center’s doctors are specially trained to deal with elderly patients with multiple chronic diseases and the social barriers to care compliance.

“It's a completely different model of delivering care,” Hurteau said. “It's high intensity, the office visits are often extensive in length.” By shifting inpatient care to the Breakthrough Care Center, the center achieves utilization performance statistics “very near what we see in the rest of the population, yet are much higher acuity and have a much higher risk factor attributed to them,” Hurteau said.

Andrea Hurteau’s interview begins at the 42:10 mark in the podcast below:

Across the healthcare industry, the push is to deliver value rather than volume with value-based payment programs being the financing mechanism to drive change. Roadmaps to Value-based Profitability: A Practice Transformation Guide is the perfect starting point to gather information about how to prepare for, and maximize, your participation in value-based payment models. 

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