Success in the world of managed care: Opportunities past primary care

As value-based care and risk-based contracts become a mainstay of today's healthcare environment, it is more important than ever for providers to be laser-focused on outcomes, which directly affect the bottom line for payers, providers and patients.

During a December Becker's Hospital Review webinar sponsored by Sound Physicians, Robert Bessler, MD, the founder and CEO of Sound Physicians, discussed the current value-based care landscape and operational strategies for managing and improving outcomes.

Five key learnings:

  1. The biggest challenges in healthcare are well known. Healthcare economics are as complicated as ever, and the traditional fee-for-service economic model is unsustainable. At the same time, clinical outcomes are poor and many patients are dissatisfied. "All of us who have been patients believe there could be a better model to serve our needs," Dr. Bessler said.
  2. Enter the new era of value-based care. CMS has indicated it will move to mandatory bundles in 2023, presenting the average hospital with a new, eight-figure risk it didn't previously have, Dr. Bessler said. By 2025, it is expected that 60 percent to 70 percent of healthcare payments will be value-based. However, that doesn't mean providers should focus on lowering costs; rather, they should focus on improving outcomes, which will lead to lower costs, Dr. Bessler emphasized.
  3. A main area of focus should be inpatient care. Despite innovation and new models in primary care, 50 percent of healthcare spend continues to happen in the inpatient setting, representing $1.9 trillion. Primary care has been a huge focus for years, but the times during and after the admission and discharge process deserve a closer look. "Even the best groups still spend over 50 percent on the acute episode or on the part they really have almost no control over," Dr. Bessler said. "The acute episode is underappreciated in value-based care … and that 50 percent of spend will continue to increase if not addressed."
  4. Operating principles for acute episodes can help manage costs. Sound Physicians developed five operating principles for managing costs of acute episodes in a value-based environment. These five principles are:
    • Aligned incentives and provider accountability for managing the total cost of care
    • Purpose-built clinical workflow enabled by technology
    • Clinical focus on patients most at-risk for adverse events
    • Continuous physician oversight, real-time analytics and performance management
    • High levels of collaboration with primary care physicians, post-acute providers and plans 
  5. Outcomes should be — and can be — reproducible. For example, after a patient is discharged from the hospital, Medicare pays for a certain number of home health visits in the first month. Sound Physicians found that outcomes are better when those visits are front-loaded shortly after a patient gets home. Ensuring consistent front-loaded scheduling of home visits, rather than arbitrarily visiting patients or visiting only when a home health agency has availability, made a difference in outcomes. 

Another opportunity: eliminating what Dr. Bessler calls "lazy medicine" to prevent unnecessary after-hours hospital admissions. For example, when an elderly patient with dementia and a long medical history has issues at 3 a.m., it can be easy to admit them. Telemedicine has helped skilled nursing facilities broaden care after hours through remote consults that can often keep patients out of the hospital. Consistent, reproducible practices improve outcomes and lower costs.

Value-based care is here to stay. In this environment, organizations like Sound Physicians have pioneered ways to be successful in a different reimbursement and payment landscape. Their successes serve as lessons for the years ahead.

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