Providers Will Continue to Shift to Value-Based Care in 2017, but Challenges Remain

Dean Stephens
January 5, 2017

The transition to the Trump administration is just weeks away and the healthcare industry is bracing for major changes – including the possible repeal of at least some of the major portions of the Affordable Care Act.  Despite facing many unknowns, a survey of the membership of the American Medical Group Association (AMGA) reveals that the healthcare community believes the country’s shift from fee-for-service to value-based care will continue through 2017 and beyond.

AMGA’s second annual survey on taking risk, detailed in a white paper, reflects the view held by many healthcare industry experts that value-based care is the future. But AMGA warns that the pace of the transition to risk is slowing. Not because risk-based contracting doesn’t work, but because there are impediments to progress that policymakers must address for value-based reimbursement to succeed.

Medicare fee-for-service revenues are expected to decline 23 percent by 2018, while revenue from Medicare Advantage and Medicare Shared Savings Program/ACOs are expected to increase roughly 20 percent over the same period. In the commercial market, participants expect a similar decrease in fee-for-service revenues of 21 percent. However, participants expect to see big gains in risk-based reimbursements in the commercial market, predicting a 152 percent increase in revenue from shared-risk products and a 47 percent increase in shared savings revenue.

In a sign that respondents are relatively optimistic about, and increasingly prepared for the march toward value-based care, 58 percent of respondents indicated they would be ready to take on risk within two years. In the 2015 AMGA survey, just 42 percent expected to be ready to take on financial risk within two years.

Despite the positive overall results, the survey reveals several challenges that are complicating the process and slowing the pace. These obstacles include:

  • An undeveloped risk market: 64 percent of respondents noted there were no or limited commercial risk products available to them. Similarly, respondents reported that their reimbursements are mostly fee-for-service since that’s the model that most Medicare Advantage plans offer
  • Inability to access claims data: Many payers do not share the information that providers need to get a complete picture of their patient populations, making it nearly impossible for them to manage quality and costs.
  • Inadequate and nonstandard data: Respondents noted that when payers do share data, it’s often not useful. Additionally, the lack of a standardized format for submitting data to payers creates a huge administrative burden and increases costs for providers who must submit information to different payers in different formats.
  • Financial limitations: Transitioning to quality is expensive. Survey participants noted challenges such as increased staffing needs – including clinical and IT staff – and infrastructure upgrades that are costly and time-consuming to implement. Further complicating matters is that providers have limited access to capital, making it extremely difficult, particularly for small and independent practices, to make the investments necessary to succeed in risk. 

AMGA noted that the participants in their 2015 survey cited many of the same challenges, indicating that very little has been done to address the issues. The group stressed that policymakers in the new administration must take up the work of removing these obstacles as soon as possible. If not, they warn that the transition to value-based care is in danger of slowing further – or stopping altogether.

To learn about how Talix is helping providers prepare for value-based care, read about Talix’s risk adjustment tools and check out related resources here.

[Image credit: Dialysis Technician Salary]

Dean Stephens is the CEO of Talix.
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