By Graham Brown, MPH, CRC, Vice President, and Lucy Zielinski, Vice President, GE Healthcare Camden Group
With the transition to value-based payment, medical practices are aligning with Accountable Care Organizations (“ACOs”) and clinically integrated networks (“CINs”). These enabling business structures, with the new payment models, require a new level of support to medical practices. A true Population Health Support Organization (“PHSO”) is the perfect fit in a dynamically evolving delivery landscape.
Strategically, a PHSO aims to integrate providers, hospitals, payers, and services across the continuum of patient care. The interoperability between each of the entities reduces fragmented patient care and serves as the bridge between healthcare silos. A PHSO is the key platform to help providers transition into the new world of medicine by providing infrastructure for physicians to reshape and drive patient-centered care and engagement via efficient management of patient populations. It is a sound structure for those starting and maintaining a CIN, or simply for those managing medical practices that are evolving to meet the demands of the future delivery system. Much like Management Service Organizations (“MSOs”) of the past, a well-designed PHSO may also support physicians who wish to remain and thrive in private practice but still collaborate with other providers across the continuum.
Setting the Objectives
The objectives of a PHSO are three-fold: support physicians in sound financial management, quality improvement, and infrastructure needed for population health. These include moving the needle on quality measures and outcome performance, controlling total cost of care, and providing improved patient access to medical care. The goal is to improve patient loyalty and experience, ultimately keeping patients in the organized system of care. The PHSO also acts as an aggregator of key patient and administrative data; so it may become the conduit for the transfer of knowledge critical to success in managing the health of populations.
PHSO vs. MSO
So how is the PHSO of tomorrow different from the MSO of the past? The PHSO is a vehicle to connect all the dots for the transformation from the old fee-for-service to the new value-based payment models. There are many benefits to organizing and operating a PHSO to support physicians’ transition to value-based care delivery, including:
- Integrating physicians with the organized delivery system of care, which supports ACO and CIN initiatives
- Providing a contracting vehicle that allows and supports providers to assume risk and manage it effectively.
- Coordinating the care management services across the continuum and managing transitions of care from one setting to another
- Enhancing system interoperability to exchange and share data among the providers to support care delivery
- Improving financial performance and managing the complexities of practice management
- Ensuring compliance with CMS programs, such as MACRA, and avoiding payment reductions
- Supporting consumerism by creating a unified brand focused on consumer experience and loyalty
- Managing the revenue cycle and coding processes (i.e., diagnosis coding, chronic care management requirements, Hierarchical Condition Categories ("HCC")/Risk Adjustment Factor ("RAF) to support value-based contracts
- Providing education to physicians—both employed and independent—on topics such as industry trends, leadership, care redesign, etc.
Whether physicians are employed or independent, the PHSO can support them equally while providing a vehicle for improved operational and financial performance.
Where to Begin
Systems should begin by assessing their employed medical groups and conducting outreach to independent, affiliated medical groups to determine needs, timing of the value-based transition, and identify the gaps. These become the starting points for core PHSO services. An existing CIN, ACO, or MSO could evolve to become the PHSO. The key to success is either designing a new or adapting an existing organization to fill the identified gaps of support services needed to be successful under changing reimbursement and care delivery models. Lastly, the PHSO can be used to gain new relationships while strengthening existing relationships with physicians. These partnerships will allow the collective organizations to ultimately improve the health of the populations they manage.
The healthcare delivery system and corresponding reimbursement models are undergoing significant change…which is unlikely to slow down. The old ways to practice medicine will no longer work in the world of a value-based payment system. A transformation of current practice structure, business strategy, and partnerships along the continuum of care will play key roles for success in the new healthcare world.
Mr. Brown is a vice president and clinical integration practice leader with GE Healthcare Camden Group and has over 25 years of experience in the areas of payer negotiations, program administration, and change management with healthcare provider, payer, government, and human service clients. He is an experienced leader in business planning and implementation for clinical integration and accountable care organization development across the U.S. He may be reached at email@example.com.
Ms. Zielinski is a vice president with GE Healthcare Camden Group. With over 25 years of experience in the healthcare industry, she specializes in helping private and hospital-owned medical groups achieve top financial and operational performance. Such optimization is achieved through physician-hospital alignment—including clinically-integrated networks, strategic planning, practice transformation, coding and revenue cycle improvement, physician compensation plan design, and health information technology, and data analytics optimization. She may be reached at Lucia.Zielinski@ge.com.