How Experience in Alternative Payment Models Put Providers a Step Ahead in Pandemic Response

Responding to a pandemic requires both public health and population health approaches.

Many of the capabilities that providers have implemented to maintain the health of their communities during COVID-19 are population health activities. From engagement via telehealth to risk-stratification of patients, these capabilities are routinely employed by providers in alternative payment models (APMs).

It’s little surprise, then, that in a survey this spring, Premier found that participants in APMs heavily relied on their population health capabilities to manage the COVID-19 pandemic and keep people staying at home healthy. Providers’ population health aptitude allowed them to leverage existing partnerships across the continuum of care, as well as claims data, to coordinate the care of their patients more rapidly than their counterparts.

Here are four population health capabilities providers in APMs were ready to deploy when COVID-19 hit.

• Telehealth and virtual health. New data from Premier showed virtual visits to ambulatory settings increased 149X in aggregate during the first wave. Providers in downside-risk APMs had prior experience deploying telehealth in Medicare fee-for-service (FFS) through available telehealth waivers. Accordingly, more providers in APMs had a head start, and were able to more fully leverage existing telehealth capabilities during the crisis compared to providers not in APMs, 91 percent versus 81 percent. Most notably, given the limited post-acute care options, Premier members leveraged flexibilities in Medicare FFS to establish mobile integrated health or hospital-at-home programs. These setups enabled providers to discharge patients to home earlier, providing them with equipment and diagnostic virtual technology, while increasing in-hospital capacity for other patients.
• Care management. Care management techniques kept lower acuity patients at home, allowing for triaging of health conditions from afar and the ability to monitor for suspected and confirmed COVID-19 cases. One of Premier's member health system created COVID-19 kits that were sent home with patients with essentials including a thermometer, Gatorade and a phone number to call if they had concerns. Moreover, many organizations were able to leverage their care management teams to assist with post-testing follow-up, which provided for the ability to respond more rapidly to positive results. According to the survey, 82 percent of APM participants leveraged care management to support COVID-19 and other patients, as opposed to 51 percent of those not in APMs.
• Use of a high-value post-acute network. Providers in APMs have established partnerships with post-acute care providers as a mechanism for reducing costs and improving quality, and were therefore able to leverage these high-value post-acute networks more than those not in APMs (40 percent compared to 18 percent). Building on established relationships, health systems worked closely with post-acute providers, having daily calls to understand post-acute capacity, PPE availability and establishing new processes to ensure successful care transitions.
• Population health data systems. Integrating claims and clinical data has been an integral step in understanding and deploying resources to manage populations in APMs, and claims analytics tools can provide reports that make this data actionable and meaningful. This information allows the ACO to provide care management for patients with complex medical conditions, work more closely with post-acute providers, partner with community organizations around social determinant needs, and develop relevant and specific care protocols. Forty-three percent of providers in APMs used population health data to manage and predict COVID-19 cases, versus 20 percent of others. Charleston Area Medical Center (CAMC), for example, used claims analytics intelligence to stratify high-risk beneficiaries at the start of the pandemic. By late April, CAMC had called more than 600 patients within its ACO population, revealing patients with potential symptoms of COVID-19 or exacerbation of their chronic diseases, and serving as a compassionate touchpoint for patients who were socially isolated. Read more about how ACO claims data helped save at-risk patients during the pandemic.

Beyond the immediate COVID-19 response, population health capabilities have helped providers define their reopening strategies.

More providers in APMs are employing strategies to recoup revenue in reopening, compared to others, per Premier’s survey. Some of these strategies include creating patient backlog plans (91 percent of APM participants versus 66 percent of others) and communicating plans to convey to the community when it is safe to seek care in facilities (85 percent versus 62 percent). As with managing populations during the crisis, more providers in APMs are also using historical data to define reopening needs (56 percent versus 35 percent).

The survey illuminated that providers see enhanced data analytics as a critical component to the new normal, managing demand for services, matching resources with patient needs, forecasting patient volume and mitigating risk for specific patient populations. And, it showed there is no time like the present to accelerate movement into a value-based care model. The country is facing unprecedented levels of deficit spending and a more rapid trajectory to insolvency of the Medicare Trust Fund. These organizations are future-proofing for a world with payment cuts in FFS and an emphasis by Medicare for providers to accept two-sided risk. Several of Premier’s member health systems noted they are using the reopening phase as an opportunity to accelerate population health redesign across their continuum.

Despite having a head start over other providers, participants in APMs are still facing uncertainty.

Many APMs are built on a FFS chassis in which participant providers receive FFS payment, and costs are retrospectively reconciled by the payer. While APM participants have received provider relief funds, many will not be able to close revenue gaps created this year due to the decrease in encounters.

Additionally, the APM entity may face financial difficulty due to the surge in COVID-19 patients and the added cost associated with higher acuity patients who will now be seeking care as providers and facilities reopen. According to the survey, 54 percent of respondents in two-sided risk APM models across all payers anticipate incurring losses that must be paid back to some payers.

While Centers for Medicare & Medicaid Services (CMS) APMs have COVID-19 mitigation approaches in place, providers in APMs need COVID-19 mitigation approaches across all payers, as well as continued adjustments of these programs moving forward. These changes should reflect the evolving clinical and financial experience induced by the pandemic, both now and going forward – including programmatic elements such as financial expenditure benchmark setting and adjustment, and risk score and attribution methodologies.

So, what’s next?

Providers are giving consideration to the temporary regulatory flexibilities that CMS rolled out during the pandemic should be made permanent, and last week, President Trump signed an executive order to expand access to telehealth services during the pandemic. Premier’s survey showed that telehealth flexibilities (93 percent of respondents) and workforce flexibilities (59 percent of respondents), such as physician supervision and scope of practice requirements, ranked as top flexibilities providers wish to maintain after the public health emergency.

Providers in APMs have long been focused on strategies that help advance appropriate and necessary care, and empower the patient with methods, partnerships and tools to manage their health. COVID-19 has yielded a greater propensity for providers toward risk-based models. Population health strategies are ones the industry should continue to spread – and incent – moving forward.

The movement to value is happening now. Learn how Premier’s experts can help assess your readiness for an alternative payment model and contact us to help maximize your performance.

Further reading.

• How to Pandemic-Proof Our Healthcare Payment System
• How ACO Claims Data Helped Save At-Risk Patients During the Pandemic
• Premier Recommends 24 Regulatory Waivers Be Made Permanent After COVID-19
• Five Keys to Building Successful Two-Sided Risk Models