Climbing the Ladder of Risk-Based Contracts

Risk-based contracts are revolutionizing the healthcare industry, prompting a transition to value-based care. In this episode of Value-Based Care Insights, guests Cliff Frank and Dr. George Mayzell explore the key aspects of risk-based contracts and provide actionable insights for physicians and practitioners navigating this transformative shift.

KEY TAKEAWAYS: 

• Internal communication is vital in risk-based contracts.
• Data can be utilized for proactive patient interventions, aligning primary and specialty care.
• Clinicians must promote appropriate care settings, strengthen patient relationships, and build trust in value-based models.

LISTEN TO THE EPISODE:

 

 Transcript:

Daniel J. Marino: 

Welcome to Value Based Care Insights. I'm your host, Daniel Marino. On the show, we've spent quite a bit of time talking about different aspects of risk based contracts. And, you know, we focused a lot of the attention on how to engage in a strong risk based contract. What are some of the things that we need to think about as we're preparing for either discussions with payers or thinking about the data that's going to prepare us for some of those discussions and even some of the contract elements. It's been great discussions and even the last 1 that we had with our partners, Q.R.C. We talked about these risk based models and quality, which is extremely important to looking at the performance of these contracts. 

But an equally important element of the contract is what happens once the contract is signed, and frankly, that's really where the work starts. Well, I am pleased to have today, two great gentlemen. Cliff Frank, Dr. George Mayzell, join me in the conversation about that. And just as a little precursor, George and Dr. Mayzell wrote this great article for HFM. It's in HFM magazine. It was just released in the summer 2023 edition. It's entitled Six Actions for Physician Practices on Signing Risk Based Contracts. We'll put the link in some of the liner notes so you can get it. It's a great article. So, here to discuss this is Cliff and George Mayzell.  

Gentlemen, welcome to the program.  

Cliff Frank:

Thanks.

Dr. George Mayzell:

It's good to be here.

Daniel J. Marino: 

So, George, maybe we could start with you when when we negotiate these contracts. Obviously, they're different than fee for service. There's typically a fee for service element in here, but we're focusing on different things. And hopefully, by the time we get to risk based contracts some of the providers are at least used to tracking their outcomes are capturing a few things. But what do you see is a sort of the real culture differentiators that need to occur with physicians and their practice as we engage in a risk based contract.  

Dr. George Mayzell:

Yeah, I think you sort of summed it up in the question. It is a cultural difference. And some of it is making sure everybody's on board. So there's a lot of internal communication that has to happen. All the physicians and administrators have to understand this is going to be different. And so it's not just about, you know, seeing as many patients as you can and running from room to room as fast as you can. All of a sudden, you have to take a different approach. And you have to understand that approach is looking at not just maximizing RVU's, but maximize the care they give patients. So, all of a sudden you using data to drive decisions. You're looking outside the office. You're thinking about the patients that don't come in the office, not just the ones that come in the office. So, all of a sudden you're thinking is not insurance based when you're thinking insurance based, " It's okay. If I have to give lab results, I have the patient come back because otherwise there's no reimbursement." So, all of a sudden you're thinking, "Okay, what's best for everybody? What's efficient?"  

So, by phone calls, by telehealth, you can start to do what makes sense to maximize revenue at the same time you're maximizing care. But the thinking is different. It has to be data driven and a lot of it, you just have to get everybody on the same page. Otherwise, if you start having folks that are still trying to practice themselves under the old fee for service model, they can really disrupt things. So, everybody has to be engaged. Everybody has to be on the same page. And the key is communication and information flow. 

Daniel J. Marino:

Right. Well, I think the one thing you mentioned, which I fully agree with is physicians in a fee for service world, you're really used to managing that patient, that encounter, right? And we need to think broader than that. You have to think about the population that you're managing and not just the patients that are coming into the office. But the patients that you don't necessarily see that you're still responsible for. Cliff, when you've worked with different practice leaders per se, and you're focusing on these contracts, and we're looking at some of the, you know the populations that were really responsible for those attributed lives, what are some of the indicators? What are some of the things that you've been able to get across to the providers to help them understand, maybe where to focus some of their attention?  

Cliff Frank:

Well, George said it best. It's not just the patients who are in the office, it's the ones who have a high risk score and they're not seeing a specialist and they're just a ticking time bomb. You know, if you're a fee for service, you could just wait around with a catcher's minute. When somebody gets in trouble, you're there to help them out. The name of the game here is to get ahead of that. So, identify patients who have chronic conditions who aren't getting optimal care either the patient's not engaged or the patient's care is fragmented.  

Find the patients who are going to the ER for a whole lot of treatment that really could be done elsewhere. Change your scheduling algorithms so you can see these patients quickly when something hot occurs rather than have it kind of spiral out of control. And then you've got a mess on your hand. It's simply, it's the difference between reacting and playing heads up ball.

Daniel J. Marino:

Well, you have to get the data, right? You have to get the data. You have to understand what's occurring with that population. Do you feel that is this sort of the practice manager's responsibility? Is it a sort of a new capability of these practice managers that we should be incorporating into their job descriptions, or is it somebody else within the network that should be providing that information to the practice on the attributed lives. The number of patients that are being seen in the office versus that aren't being seen and and those that we have to see in schedule management, Cliff, like you said.

Cliff Frank:

It depends. I've seen it work both ways. I mean, if you have a care manager in the group, usually a nurse care manager or, or at least someone who is a data savvy, a lot of that stuff can be done in the practice. In many cases, though, that doesn't exist. And so, some sort of central support organization has to do that through an IPA or an ACO or some other collaborative organization. And in some cases, the plans do it in support. Part of that gets to timeliness of data, how granular the data is.  

And most importantly, is the data actionable?  

Daniel J. Marino:

Right.

Cliff Frank:

Just because I know something's out there that doesn't tell me what I got to do. And, you know, there are lots of things that are going on that, you know, the doctor or the office really can't bend the trajectory of that disease process and in other situations, they can't. And so picking and choosing your spots as to where you're going to provide these prospective interventions really becomes important. The other piece I'll just mention is all this is happening, not in a vacuum. It's happening amidst a regular fee for service world, right?

Daniel J. Marino:

So it's all intertwined, right? So you're sort of...

Cliff Frank:

These patients are not tattooed. You know, on their forehead they're an A. C. O. Patient or an I. P. A. patient or you know, whatever. So, a lot of what the doctors end up doing since they don't really practice in a bifurcated way is they develop these new practices and new sensitivities and awareness and interventions and they apply it across the whole practice, which lifts the quality of care for everybody. It's a good thing. 

Daniel J. Marino:

All right. So, George, one of the things you mentioned in your article is you talk about the rising risk score, and you say that early identification of patients who are undergoing a significant shift in health status can enable primary care physicians to positively affect patient outcomes. I don't think anybody would argue with that. How do we get that data? So, are we relying on the systems to risk score the patients? Are there protocols that we should be having built in terms of how we identify patients and put them in these cohorts? What would be a best practice that that helps to achieve what you put in there?

Dr. George Mayzell:

Yeah, great question. Let me take a step back into because the data stuff is just such an important element of this. And it's something that hasn't been traditionally inside the medical practice. And so, when you look at data, one of the things you have to do is you have to get external data because what happens is traditionally you have EMR based data from inside the practice. 

That is not good enough. Because that only tells you, you know, who's there. So, you have to get claims data and integrate it with that EMR based data so that you can get a full look at the patient. When you look at that, that's when you start breaking down to what Cliff talked about was the acute care, which is our kind of our current model. Then Cliff also talked about the chronic care model, which is still kind of part of our care model we're not very good at but we try as well as diabetics and hypertensives and hyperlipidemics and you're trying to be more preventive. But what this does, it lets you reward you for being more preventive because you're getting early and you lower long term medical costs.  

But the biggest issue which you brought up, which is not something physicians are used to thinking about is what you called rising risk. Because that's really the thing that we've not done a great job at intervening on and so what we know is that patients that spend a lot of health care resources this year are not predictably the ones that are always going to spend health care resources next year. So, what you have to do is go back and say, "Okay, who are the ones are going to have issues?" And so, you start looking at that and you can predict them to predictive modeling. You can look at things in lab work. Maybe someone has a cancer diagnosis that pops up or a kidney, you know, something acute that's going to be turned into a chronic problem. Those are where you really want to focus your resources, because that's really where you can be most effective. So, identifying those rising risk folks is really, it's a challenge, but it's so, so important. And again, as Cliff said, how do you then move that information into actionable items? And that's tough because, you know, the care managers, in my experience it's a whole new skill set to take that predictive modeling and predictive algorithms and then intervene in a way that lowers the risk. And that's really, that's 1 of the biggest challenges, but also 1 of the most important, but it's also the most rewarding because you're taking someone who was going to have a very difficult year medically and you're hopefully preventing or at least mitigating it. 

Daniel J. Marino:

Yeah, absolutely right. Well, if you're just joining us, or you're just tuning in, I'm Daniel Marino. You listen to value based care insights. I'm here today with Cliff Frank, Dr. George Mayzell. We're talking about an article that great article that they wrote. It was recently released in HFM magazine, which is part of HFM for May.  

Cliff, let's talk a little bit about the risk component, some of the cost drivers, right? Because at the end of the day, when you look at these risk based contracts, it really comes down to how cost efficient we are in managing the population, right? So we have to manage utilization efficiently. We have to make sure we're providing care to the patient, the right care to the patient at the right time. All of those things that we talk about, how do we align that risk element with costs in a way that it really does integrate well with the physician practice so we can achieve those goals that really drive the performance of the contracts.

Dr. George Mayzell

This is where the two worlds collide, the fee for service world and the value based world. For example, you might have a set of specialists that you really like and use a lot, but they're very aggressive and you know, they view the clinical indicators for doing a particular procedure. Very broadly. Whereas, some other providers are much more conservative, thoughtful, careful, whatever adjectives you want to use. And in the fee for service world, you really don't care, you know. 

You're happy to have it. You just want the patient to come back. You want them to be in better health by the time they come back. And you know, the problem that was driving the patient resolved. But in many cases, there are multiple ways of resolving a patient, whether it's surgical, medical, You know, some sort of psycho-social support and it could be any number of things. 

Suddenly as a primary care doc in a value based panel, you care a whole lot more about which specialists are doing what to your patients and frankly, a lot of primary care docs are not really comfortable or built to have conflict with their downstream specialist.  

Daniel J. Marino:

But I think building on that, that's critical because if you look at the real cost drivers, obviously the specialty care, which is needed, I don't think anybody's arguing with that. It's the most expensive component of the care, right? So, that integration between the primary cares and the specialists. It's not a matter of how do we do it. It's a matter of of it just needing to be done, right? You have to be in to communicate. You have to collaborate. We have to be on the same page in terms of working behalf of the outcomes.

Cliff Frank:

I would just start with data. George said the doctors don't have that data. It's in the claims database and it's in broader databases that speak to clinical proclivities of your downstream network and understanding what they are is kind of basic to being successful in these value based programs. And if your specialty network goes crazy. You're still upside down.

Dr. George Mayzell:

Yeah, I was basically going to say the exact same thing. Most primary care docs really don't know the quality of their specialist care. They know, you know, the one off quality, they know how they treat the individual patient but I know there's a lot of surprises when they actually look at the data and they see kind of what's going on and it really does change behavior a lot when they see that information. So, it's not something we don't share a lot of outcomes and quality data across the different specialist and primary care. Traditionally, these new models are forcing that to happen. And that leads to things happening. 

Daniel J. Marino:

So how much does access come into play here. You know, we all have heard we got a lot of access challenges. You know, we can't get in to see a specialist for 3 months. Our primary care is booked out 4 or 5 weeks. You put in your article, which I think is great. You have to establish systems for after hours coverage. Obviously, you're talking about urging care. How does the access management come in as you become, you know, as a tool, so to speak, to drive that performance, George? 

Dr. George Mayzell:

Well, yeah. I think we all know that if you get somebody in quickly, you can resolve a problem before it becomes a big problem. The last thing you want is to someone go to the ER for a non-urgent issue. It's very expensive. ERs are not efficient places to take care of non-emergencies. So that access gets patients in a quick fashion and you know, potentially preventive or stopping a big problem. So, it could be in the office. It could be after hours. It's a relationship with an urgent care facility that you trust as good outcomes and we'll share records with you. So you can see the patient back and follow up. It's using the ER appropriately. I mean, there are certain things that you need in the ER. So, it's really about appropriate usage but allowing access to the lowest level of care that is appropriate. And so, we're not good at that because right now it's hard to get into practices. 

And so, that's we're using models that use team based care and other things that that allow that to happen efficiently with the appropriate scheduling and maybe telehealth, all those things play into what's the right thing for the patient at that moment and the best way to get care.  

Daniel J. Marino:

And so, Cliff, let me build on that for a second. I've spoke time and time again. I think, you know, the 3 of us agree with this that you have to provide the right level of incentives to get the behavior that you want. Should we be incentivizing our urgent care providers? 

Cliff Frank:

Well, I think for them, the fact that they're in the referral stream is the incentive. What I think is more important is the comp model for the doctors. If they're still on churn and burn RVUs and there isn't kind of a quality or a relationship or a direct percent of savings model that hits their income stream, you're not, you know, they're going to do what they're comfortable with, which is what they've always done. 

Daniel J. Marino:

Sure.

Cliff Frank:

So, it's really hard to just kind of layer on a value based deal and expect some significant clinical changes without it flowing all the way through the incentive system.  

Daniel J. Marino:

You need to have that and I couldn't agree with you more. We need to create the alignment of the compensation model has to align with the contracts. I've spoke with many organizations who are still have their providers on a straight RVU model, which frankly aligned well a few years ago with fee for service, but works against you in risk based contracts, right? So I absolutely agree. Let's switch the topic a little bit though. Oftentimes, when I talk to physicians about this and, you know, we talk about risk based contracts and we talk about what the providers need to do and you need to, you know, talk with them about all of these protocols and be a little proactive. 

A few of the physicians will come back and say, you know, look, there's a certain level, certain group of patients who doesn't matter what I say, they're going to do their own thing, right? They're, you know, they have choices. They can go to whoever they want to. They're going to throw their hands up. You mentioned in the article that you need to build stronger relationships with patients. Is this the way that you're working through to try to get better alignment with the patients to have them follow what that clinical protocol is? Hopefully get the outcomes that you want.  

Cliff Frank:

Well, let me take a macro approach to this before we get to the micro. This whole leakage issue where the pay you send the patient to your preferred set of specialists and the patient says, "Nah, I'm going over here to this other one or this other neurologist or what, whatever it is." That happens a lot, especially in PPO type benefits like Medicare or a regular Blue Cross product and you're still somehow at risk for all this. The good news in all of that is you don't have to fix it. You just have to make it a little bit better than it was because that leakage is already in the base year, 

Daniel J. Marino:

Right. Well, it's in the base. It's a basic cost in the base cost of care, right? 

Cliff Frank:

All you got to do, you don't have to beat the bear. You just got to meet the other guy who's running from the bear. So, you just have to be a little bit better than you were last year. Now, that's not easy, but it is a point. II'll let George kind of speak to the to the individual physician patient kind of section relationship and dialogue that that has to happen but from a from a macro standpoint... 

Daniel J. Marino:

That's a good point.

Cliff Frank:

We can be 5% better than what we were last year. That's a lot.

Daniel J. Marino:

Yeah, you don't have to boil the ocean. You just have to chip away. So, George, you undoubtedly have had to hear that. Complaint or that issue coming from physicians.

Dr. George Mayzell:

I have and here's, you know, there's no perfect system, but the advantages of a value based care. It let's the doc slow down. It's not, you don't have to see as many patients as, you know, you're not, you're not trying to hit RVU numbers. You can spend more time form relationships, build that trust. And we know that when that trust is built and better patients are more compliant and outcomes are better. So you do get that compliance. Now, you know, the other piece I always hear is, oh, I always got this non compliant patient. Yeah, you're always going to have some non compliant patients on the end of the bell curve. You know, and you do your best, but they're going to be there, but they're not going to drive really the main numbers. 

You know, if you think about statistics, most of your patients, if you spend the time, you know, we'll be compliant with what's best for them. Good communication and some trust building and all those things. So this lets the doc. Slow down the model. It frankly takes the insurance payer a little bit out of the process. So, all of a sudden it allows you to, if it's the right thing to make a phone call, it's best for everybody. It's the right thing to come in. And so everybody feels more comfortable when that trust is built. So, you know, I always encourage stocks, don't worry about the folks that are way outside. They're going to be non compliant in any situation. They're not going to be driving your practice patterns, you do your best you can with them. You know, sometimes you can win, sometimes you can't. But with the majority of your patients, they're going to do better in this model.  

Daniel J. Marino:

Yeah, no, you're absolutely right. So real quick, because we're running to our end of our show here and Cliff, we'll start with you real quick, 30 seconds. As physicians are entering into these contracts or as organizations are entering these contracts. What's the one piece of advice you'd give to practice managers or leaders or physicians that would drive the success of the contracts?

Cliff Frank:

Data, data, data. If you have good data, good things can happen. Not necessarily well, but you got a shot. If you have no data, you're done. 

Daniel J. Marino:

Perfect. I agree with you wholeheartedly and having that data translate in a way that physicians could do something with it and really make an impact with that patient. That's the Holy Grail. That's where you need to aspire to. How about you, George?

Dr. George Mayzell:

Okay, nice. Cliff stole my thunder. 

Daniel J. Marino:

He usually does but we won't talk about that. 

Dr. George Mayzell:

He does. I would add to that, "Go slow this is not easy when you're transitioning from fee for service and you're in that middle ground where you have some fee for service some value base. It's hard. Don't think about this is is just same old business is as usual. Go slow build the infrastructure, which includes the data piece, but also includes operational infrastructure. And take it 1 step at a time so that, you know, as you increase your financial risk, you know, you're going to be successful because you've gone slow." 

You've done the modeling. You've changed the behavior. You've changed the culture and, you know, you're going to be, you won't have any doubts you're going to be successful because you've already, you've already run the process and numbers.

Daniel J. Marino:

Yeah, you're already on it, worked it through. Well, gentlemen, this was fantastic is, you know, as usual. I love having you both on. We have a lot of fun with these these conversations. George, any of our listeners want to get in touch with you have an email or LinkedIn or how can they reach out?

Dr. George Mayzell:

I'm on LinkedIn. Happy to talk to you. My email is GMayzell@gmail.com. It's my personal email. That's easiest. That's what I check. So happy to have a chat with anybody. 

Daniel J. Marino:

Great. How about you, Cliff? 

Cliff Frank:

Mine is cap help, C. A. P., as in Paul H.E. L. P. like help me Rhonda caphelp@msn.com. That's my personal email as well and both George and I are both kind of sick guys because we love talking about...

Daniel J. Marino:

You do and I love having you both on it was always makes for a great conversations and I'm sure my listeners enjoy it as well. So, thanks again to both of you for coming on today. And I definitely want to thank our listeners for tuning in. Hopefully you got out a lot out of today's conversation until the next insight. I am Daniel Marino bringing you 30 minutes of value to your day. Take care.

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners