In Part 1 of “Attribution and Market Share, a Story of Growth,” I discussed whether you need to increase attribution, and how you can go about doing that. We covered a significant amount of information, so if you haven’t read it, please do that before reading this blog. When we left off, we were just beginning to discuss Group 3: people that you haven’t seen at all (and were never attributed) i.e., “Net New” which means that you’re looking for beneficiaries that you can “recruit.” This can be done by adding new practices or by creating relationships with specialty groups that lie outside your organization.
DOES IT MATTER WHOM I BRING INTO MY PROVIDER ORGANIZATION?
Starting with adding practices, the key, here, is that you have to be very careful about who you bring in. You can’t just pick the best of the best and “pad your stats” as they say in baseball. In my experience, not every office is excited to practice population health. There are many providers out there that are set in their ways, and no matter what you do, they’re not going to get on board with any initiatives your provider organization requests them to implement. Therefore, even if it’s a large practice, I wouldn’t recommend bringing on those offices who are not open to Value-Based Care (VBC) because it will actually hinder your opportunity to achieve shared savings. This is a clear quality over quantity scenario, and you can run an inverse analysis to help you identify the first medical groups or practices that you’ll want to talk to.
You can use both your assignables list(s) and your beneficiaries whom you’ve lost plurality of, find out what ZIP code each beneficiary lives in, and discover if there are any nearby affiliated medical practices. If you find, instead, that the closest medical practices are not currently working with you, those are your “Net New.” Reach out and see if they would consider joining you and would be open to making the transition to value. If they are, then that could be a great fit. Chances are, in convincing new practices to make the transition to value, you’ll likely have to recruit the individual providers within the practices as well since what you’re asking for is a culture change. Keep in mind, you’ll want to research how those practices have performed. Are their physicians employed or not? Do they have a lot of specialists?
If you come up against practices that are not a good fit, then you’ll ultimately have to decide whether they are at least someone you can form a referral network with so that you can develop a relationship with those beneficiaries.
There are a few inherent challenges you may face that I will just touch on for the sake of some brevity. For instance, recruiting providers themselves comes with the frequently difficult task of educating them on why they should adopt a population health mindset. I know this because the practice I used to work for required multiple conversations over about a two-year timespan to get them to join an ACO. It worked because they’re the top performing practice in the top performing ACO in the United States (per 2020), but it definitely took time because being open to VBP, like many new experiences, often requires repeated exposure.
There’s also occasional politics that come into play. Providers are often competitive by nature, so know that recruiting certain practices may mean you’ll lose out on other practices simply because of personality clashes.
My personal recommendation, since this part of growth is partially a sales job, is to start small. If you try to sell the whole of value-based care, it can become overwhelming to practices and providers that are new to the subject.
The conclusion should be creating relationships with specialty groups that lie outside your organization, and this can be helpful when you do not have particular services within your own provider organization. In this instance, you’ll have little choice but to partner. The key is, just like with adding new practices, you’ll need to invest in building a relationship of trust and know that the other practices are open to population health. There is certainly a “feel” component to this.
GROWING MARKET SHARE
By adding the “Net New” beneficiaries, you’ve already begun taking the first steps down the market share path. However, adding beneficiaries will also provide leverage in payer negotiations.
Think of this equation: Size = Power. The larger a high-performing organization is, the more leverage they have in payer negotiations. Why is that? Well, it has to do with the amount of risk the payers are willing to accept. Looking at this from the payer’s point of view, If an insurance company is going to enter into a risk-bearing contract with you, they want to know it’s a safe bet.
Each component of population health (continuous attribution, quality of care, appropriate facility utilization, appropriate coding, and overall spend) now begin to merge into one large interconnected system. The key word, here, is performance. If you have a large patient population that you serve, and you can prove that you do a good job taking care of them via performance analytics, then there’s a great chance that most payers are going to give you a little extra as a “reward.”
A 2017 Health Affairs study showed that that insurers with greater market shares negotiated lower prices for office visits with the same providers compared to insurers with smaller market shares, but that price differences were smaller between insurer market share categories above 5 percent. The same thing can be said about practices, and this ties back to that quality over quantity component mentioned earlier. The practices that have greater market share have the ability to negotiate higher rates. Even if target practices aren’t great at practicing population health, as long as they’re open to learning, you can work with them. Some of those practices may even turn into superstars later down the line.
I’m going to assume you’re already doing well with adding “Net New” beneficiaries. Therefore, you’re almost ready to enter into negotiations. Keep in mind, there are a series of categories that you should be showing payers as you discuss who you’re covering and how much you want:
- SIZE – As we’ve been discussing, attribution certainly plays a role in this. If you can show the number of beneficiaries you see across your entire population, then you can bet that a bigger organization is going to have more negotiation power. Just make sure that you go about doing it the right way (See parts 1 and 2).
- QUALITY – Perform well and meet your quality measures. At least pay attention to your Annual Wellness Visit percentage, HbA1c percentage, and Mammogram percentage so that payers know you’re on top of patient care (this lowers their risk).
- CODING – You’ll want to come to the table armed with your HCC Risk score for your population, and you’ll want to be able to show that your team has done an excellent job in coding your patients appropriately. Appropriate coding is the only way that payers know how sick your patients are and give you credit for the hard work you’re doing. This ties back to the AWVs mentioned in the previous blogs as this is a great time to jump on any potential coding inaccuracies and recaptures.
- UTILIZATION – Can you prove that you’re gradually reducing the number of beneficiaries who are heading to the ER unnecessarily? Can you ensure the beneficiaries still using the ER are doing so appropriately? Can you prove that you’re reducing the number of 30, 60, and 180 day IP readmissions? This kind of information is critical because it tells payers, “I’m a good bet that you’ll pay out less and less each year you’re with us” because we are on top of the patient care for our population.
- FINANCIAL – Finally, we look at financial last. Why? Because the reality is that your financial health is usually the result of #s 1-4 being taken care of appropriately. If you’re gradually growing, you’re coding appropriately, you’re getting patients in for AWVs and follow-ups, and you’re reducing unnecessary acute care utilization, your financial standing should improve over time.
The key takeaway from this is that good data is the backbone of any good contract negotiation. As an aside, just make sure that whether you build your own in-house solution, or work with a vendor, you know your data is accurate. Also, when you’ve properly taken care of the five components above, you’re not only turning yourself into a payer’s dream, but you’re also becoming a great organization for your patients. It’s really a triple win: Patients, Payers, and your organization!
Grow smartly, grow diligently, and acquire the data you need so that you can head into the boardroom knowing you’re ready. Speed isn’t always your friend. Slow and steady wins the race, or should I say wins the rates.