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Smaller practices invest in costly transition to value-based care

While certain programs favor large systems, plenty of providers are proving that scale doesn't always matter.

Jeff Lagasse, Associate Editor

As value-based reimbursement leads healthcare providers to dig deep for new technologies and create team structures to handle the switch, smaller providers are struggling to cover the cost. 

But just because it is hard, doesn't mean it's impossible. By carefully navigating the options that exist, a smaller practice can thrive in a value-based landscape, experts say.

"Even with meaningful use and other incentives, it's a much heavier lift for smaller practices in some cases to develop and support the care teams that are typically considered requirements now for enacting value-based care," said Karen Handmaker, vice president of population health strategies at Phytel, an IBM company. "Still, we've seen many, many examples where smaller practices can hit it out of the park even better than big ones."

[Also: AHIP: No matter the political landscape, value-based care will continue]

It begins with the culture and style of the practice, which Handmaker said often begins with a physician who's passionate about transforming care and doing the right thing.

"There are examples of very charismatic and very passionate people who have done amazing things by the power of their personality, their management style, how they engage with patients, how they use the resources they do have at hand to engage and stay with them," she said. "It becomes almost personal in a different way than it would be if you were part of a very large practice."

Without that vision, she said, organizations fail.

[Also: 'Slow and steady' philosophy should rule volume to value transition, HFMA ANI expert says]

There are practical considerations, however, especially in terms of technology. The smaller a practice, the fewer resources are readily available. That means a small-scale practice may be forced to collaborate, or even align, as part of a clinically integrated network -- even if they're not going to be owned by it.

These partnerships allow a practice to easily see performance measures, and support cohorts of patients who are at risk, rather than waiting for them to succumb to an acute event.

Handmaker said there are sometimes grant mechanisms that can help, as well as regional extension centers that provide support. There are a number of different ways to collaborate with some of the bigger players. If there is a mutual benefit, a small practice could potentially piggyback into technologies used by the larger systems in the community so everyone is linked to a common contract or network. Small practices, said Handmaker, are going to need those resources.

[Also: Cultural competency crucial to patient engagement, bridging communication gap in hospitals, expert says]

"I don't think anybody can operate 100 percent alone," said Handmaker. "It's hard for anyone to be totally independent. It's not really feasible if they want to maximize their impact. The small practices can still stay independent but will still need to figure out how to collaborate with their colleagues in their communities. A large part of the intent of value-based care is to push care out into the community and make care something that happens in a collaborative way."

Experts do agree on the need for robust patient engagement initiatives in order to stay relevant. But "patient engagement" can be a somewhat vague term.

Jonathan Niloff, MD, an advisor with Qcentive who formerly served as a chief medical officer at McKesson, said the term means different things to different people.

"It can mean being able to proactively communicate with patients about their care," said Niloff. "It can mean outreach for gaps in care. It goes to the next step for the high-risk population to have risk managers reaching out by phone on a regular basis. It goes to a web presence. It even goes to wellness programs. Or it can expand in some fashion to the monitoring of high-risk patients in the home with monitoring devices. With respect to patient engagement, the best approach is to say, 'One size doesn't fit all,' but to have a tiered plan that employs the right type of engagement based on the patient's needs, and receptiveness to that engagement."

Jeffrey Galles, CMO at Oklahoma-based Utica Park Clinic, said patient engagement is about wellness as opposed to sickness. For instance, setting expectations for patients that a higher number of visits, particularly for chronic ailments, is better for both the patients and the providers. 

"The support around population health requires an investment, and for a small practice, it might be virtually impossible to hire, say, a nursing coordinator to do outreach. Licensed practical nurses have come in to do spreadsheet management and utilize population health tools. That's an investment most practices can justify because the return on that investment is substantial."

For Galles, identifying opportunities to transition to value-based care was market-specific. He started slowly, looking for tools the organization could use to drive volume into its practices. Early on, they identified patients with chronic conditions who were coming into the practices once a year, or every other year, and not getting the actual care they needed. 

Galles and his team sought out vendors who could offer an automated process for seeking outpatient registries -- something that certain electronic health records will allow, as well. The results were tangible. Patients were coming in for needed care and driving volume. They were undergoing important procedures such as blood pressure management and getting their lipid profiles drawn.

Before those outreach efforts, Utica Park Clinic wasn't doing a lot of measurement for quality metrics. It was completely volume-driven from an outpatient perspective, said Galles, and the concept of value was limited to things the organization did with the Centers for Medicare and Medicaid Services in relation to the physician quality reporting system. It was limited and not timely. They needed a registry.

"Smaller organizations can do some of this with an Excel spreadsheet and some staff education, and with the right electronic medical record," said Galles. "But most would struggle with the manpower requirements, and to do it efficiently. When you're reaching out to a population of 250,000, those tools are almost mandatory."

Galles said his practice has focused on Medicare wellness visits. "There's a substantial amount of revenue associated with Medicare wellness visits, and there are a lot of patients who haven't been educated about the value of these visits."

Utica Park Clinic partnered with medical groups and insurers, enabling the sharing of data with independent physicians as well as larger groups. This aided outreach efforts, as the organization was better able to identify care gaps. Galles said he would recommend reaching out to different payers to ask if they would share quality data.

It all goes back to the notion that the move to a value-based model is easier when one isn't going it alone.

"Smaller systems don't have the same leverage that larger systems do, so that's another incentive for them to align with some of the bigger players in their community," said Handmaker. "The small practices definitely still have a challenge, but there's still a lot of them out there and it's going to be increasingly important to work with other organizations, and band together to share these resources."

Twitter: @JELagasse

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