As healthcare administrators versed for decades in the intricacies of successful risk-based practices, we read this article with interest. However, the author seemed to talk around the subject, ignoring the elephant in the room of risk-based payment. Call it what you will – value-based, risk-based – the concept is the same: being paid to manage care. In our experience, it takes micro-management to be successful in risk, and that’s where the paths diverge.
The value-based paradigm is a toe-in-the-water good step in moving away from the fee-for-service mentality of lever-pulling payment (I do once, get paid once; I do 10 times, get paid 10 times) and its incentive to (perhaps) do more. Value-based payment (VBP) asks us to focus on what the system is delivering to the patient, namely outcomes. These models start with incentivizing providers to manage specific patient populations and medical conditions to achieve measures that have proven successful (in other words, promote patient health and well-being while lowering costs). That’s the part this article doesn’t talk about though, and it’s the crux of risk-based payment. The leap is huge from VBP to risk and readers of this article would do well to study the differences carefully before moving into any shared risk arrangements, which are presented as one step removed from the pay-for-performance of most VBP.
If your practice is financially sound, maximizing incentive payments for achieving quality measures, and you have a good handle on the data received and generated by your practice, the next step on the risk-model continuum might be worth exploring. The road from study to implementation is long and practice structure is a big consideration. Groups with many resources and one-stop-shop services naturally fare better than solo providers who refer all services to their hospital-partner.
Successful risk-based providers (meaning, lucrative practices with stable patients) have shifted their thinking to embrace managed care precepts, and know how to operationalize them in their businesses. Long-gone are the days when capitation and risk were believed to mean you skimp on care to keep more money. It’s possible to practice honorable medicine, for the good of your patients, and still be profitable by working the system (network management, utilization review, health plan reporting and support, coding and quality) to your and your patients’ advantage. But be mindful of articles that gloss over the attention and work involved. They’re eerily reminiscent of the seemingly smooth road where Wile E. Coyote removed the sign reading, “Beware – Cliff ahead.”