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COVER STORY · STATE OF THE INDUSTRY


• We have no plans to use data analytics on any level of scale: 12 percent Have you done health risk assessment


across broad populations? • Yes: 44 percent • Not yet, but plan to do so soon: 23 percent • No: 33 percent Have you implemented care management


programs at the primary care level, in which physicians work with and are supported by mid-level practitioners (NPs, PAs, etc.)? • Yes: 59 percent • Not yet, but planning to do so soon: 15 percent • No plans to do so: 27 percent Looking at these answers, it is sig-


nifi cant that strong pluralities of patient care organizations are involved in value-based contracts; still, only one- quarter—26 percent—of respondents are receiving 10 percent or more of their overall reimbursement via two-sided risk. That figure would be far higher


among large multispecialty groups, of course. Indeed, in that regard, major industry-leading associations, such as the Arlington, Va.-based AMGA (American Medical Group Association), are pushing ahead to support value- based contracting, on the policy, stra- tegic, and operational levels. Asked what the next 24 months look


like, in terms of policy around payment innovation, Jamie Miller, senior director of government relations at AMGA says, “From a value perspective, Congress and the administration spent over $3 trillion on COVID and will spend some more, and our members will be leading innovation. I think the medical group model is the way towards the future of medicine, and we’re just going to continue to promote the medical group model. And going forward, there’s obvi- ously going to be a lot of discussion about how our system progresses.” “There are two things going on,” says


Darryl Drevna, AMGA’s senior direc- tor of regulatory affairs. “One, AMGA and its membership will continue to go towards value-based and population health-based models, because there’s really no alternative. That said, what HHS [the Department of Health and Human Services] is going to do will depending on who’s staffing HHS, and how we come out, post-pandemic, and what our capacity is. We’re going to keep moving ahead, and I’m going to be working to make sure that HHS and Congress see us.” Chet Speed, AMGA’s chief policy


offi cer, says that there’s no stopping the value train in U.S. healthcare. “For


the next six months, it will all be about COVID-19 and survival; but in the next 24 months, it will be about value. “Fee- for-service payment is still the domi- nant payment system in the country; and though value-based delivery is something that all of our members embrace, it involves a signifi cant clini- cal, fi nancial, and operational redesign. Our members are all committed to it, but it’s not easy; it’s very complex, and takes time. And the payers have to fol- low suit as well.” Will payers move ahead signifi cantly


to support the phenomenon? “They say they’re doing so,” Speed says. “Most of their statements indicate the desire to move more quickly towards value- based arrangements. Some payers truly are committed; Humana certainly is. And Aetna has an ACO program with Cleveland Clinic. So they’re moving there; I wouldn’t say it’s a full commit-


management and care management work needed to make value-based care delivery and payment work. With regard to where their organizations


are on their journeys around analytics development, as the data showed, 37 percent of respondents described them- selves as “advanced” in their analytics development, and 38 percent said they were “early on” in their analytics journey. But 12 percent indicated that they have not used data analytics until now, and a further 12 percent have no plans to use data analytics on any level of scale. Looking at the intersection between


Jeff Bailet, M.D.


ment yet. If you talk to the head of HR for a major employer, they’ll say that value sounds good, but our employees demand access.”


And will the shift mean more of an emphasis on the narrowing of provider networks, or on the forcing of value at the level of individual clinicians? “Finance drives behavior,” Speed emphasizes. “Some payers are developing incentive- based contracts with individual provid- ers, so that the fi nancial arrangement will drive value through that contract. And that does get down to the individual clinician level of performance. There are a lot of components to this.”


Data analytics a true critical success factor One of the elements that will be absolutely critical to success in the new value-based healthcare system, as industry leaders agree, will be the successful leveraging of data analyt- ics to support the population health


10 hcinnovationgroup.com | JANUARY/FEBRUARY 2021


fee-for-service payment-based care delivery and value-based care delivery, Jeff Bailet, M.D., president and CEO of the San Francisco-based Altais Clinical Services, sees a very strong correlation with analytics success. Altais Clinical Services, a division of the healthcare services company Altais—initially launched by Blue Shield of California— was created to help physician groups succeed under value-based contracts, precisely by helping them to master the use of data analytics tools. “COVID really exposed the lack of resilience in the medical system, and how fee-for- service payment really is not sustain- able; it really exposed the underlying challenges with fee-for-service,” Bailet says. “And a lot of practices are no longer in business, because they lost 70 percent or more of the revenues early on. Even some sophisticated integrated health systems are really struggling right now. And that was an ‘aha’ moment, where physician leaders realized that had they had more value- based contracts, they would have done better during COVID. But you need the infrastructure, the analytics, including predictive, and clinical decision sup- port, to be successful,” he emphasizes. There is, in the industry, Bailet says,


“an acknowledgement of how powerful technology can be if it’s deployed in the right way. And there’s an aware- ness among medical group leaders that they need to pursue value, and that they need technology to do that. I serve on the Physician-Focused Payment Model Technical Advisory Committee (PTAC) for HHS, and we review proposals with stakeholders across the country. We work with CMMI [the Center for Medicare & Medicaid Innovation, a division of the Centers for Medicare & Medicaid Services]. So designing a comprehensive model is really diffi cult, but I think the payers are wanting to get into this space more forcefully. But they need a high-performing group of physicians who are engaged, who want


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