Providers experience challenges in transitioning to value-based care

Limited access to claims data, risk-based insurance contracts, and investment capital are hindering the move to value-based care, says AMGA’s Donald Fisher.

As providers seek to transition from fee-for-service to value-based care, they are encountering significant challenges, including limited access to claims data, risk-based insurance contracts, as well as investment capital.

That’s the finding of a new survey of its members conducted by the American Medical Group Association (AMGA), which represents medical groups, health systems and other organized systems of care. The second annual survey included 115 respondents representing 168 member organizations.

Although 58 percent of those surveyed by AMGA are willing to embrace alternatives to fee-for-service payments—including downside risk—within two years, according to Chester Speed, AMGA’s vice president of public policy, the transition to value-based care is slowing measurably because of a number of factors. Speed notes that the impediments identified in its 2016 survey are largely the same as those identified in 2015.

Among the obstacles to risk identified in the latest AMGA survey:
  • Immature risk market: 64 percent report none to limited commercial value-based or risk-based products in their local markets.

  • Lack of access to claims data: Providers are not able to access administrative claims data from all payers—without which it is nearly impossible to manage quality and cost.

  • Non-standard data: Providers have to submit data in different formats to different payers, creating a massive administrative burden.

  • Limited access to capital: Lack of capital is an acute issue that delays investments in the infrastructure necessary to take risk, which also drives consolidation.

  • Inadequate infrastructure: Necessary systems—including information technology—is expensive and difficult to implement, and it requires significant change management.
Also See: Providers, payers must share data to succeed in value-based care

A white paper detailing the results of AMGA’s survey is available here.

“Providers must be able to access administrative claims data in both the federal and commercial settings,” states the white paper. “Without a complete picture of a population of patients, it is virtually impossible to manage the cost and quality of a patient’s care. While some payers provide this data to clinicians, many do not.”

“The transition to risk is slowing and there are very real obstacles in the way,” added Donald Fisher, president and CEO of AMGA, during a December 8 teleconference in which the group reported the results of its survey as well as recommendations for the incoming Congress and Trump administration.

Fisher boasted that AMGA’s members are “recognized as leaders in delivering coordinated, high quality, cost-effective care” and “if we can’t do value-based care, I dare say it can’t be done.”

To reduce the hurdles standing in the way of providers, AMGA recommends:
  • Data improvements: Congress should require federal and commercial insurance companies and providers to standardize data submission and reporting processes, as well as to provide access to all administrative claims data to healthcare providers.

  • Access to capital: Congress should create a fund that enables providers to use income on a tax-free basis to invest in taking downside risk.

  • MACRA: For success under Alternative Payment Models (APMs), Congress should not penalize Advanced APMs if there are insufficient risk products in their local markets, allow Medicare Advantage revenue to count in performance year 2019 toward meeting the Advanced APM revenue thresholds, as well as allow Track 1 ACOs to be eligible as Advanced APMs.
According to AGMA, it is imperative that Congress and the Department of Health and Human Services address the obstacles standing in the way of the transition to value-based care sooner rather than later, or progress in moving away from fee-for-service could grind to a halt.

“We believe that our recommendations include federal policies to help ensure the healthcare system truly transforms to one based on value,” concluded Fisher.

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