Providers face problems in transitioning to value-based care

As providers seek to transformation from fee-for-service to value-based care, they are encountering important problems in transitioning to value-based care, involving restricted access to claims data, risk-based insurance agreements, as well as investment capital.

That is the finding of a latest survey of its members undertook by the American Medical Group Association (AMGA), which depicts medical groups, health systems and other organized systems of care. The 2nd annual survey involved 115 respondents representing 168 member agencies.

However, 58% of those surveyed by AMGA are eager to accept alternatives to fee-for-service payments—involving downside risk—within 2 years, in accordance to Chester Speed, AMGA’s vice president of public policy, the transitioning to value-based care is slowing measurably due to a number of factors. Speed points out that the impediments recognized in its 2016 survey are highly the same as those identified in the year of 2015.

Among the barriers to risk identified in the latest AMGA survey:

  • Immature risk market: 64% report none to restricted commercial value-based or risk-based products in their regional markets.
  • Deficiency of access to claims data: Providers aren’t able to access administrative claims data from entire payers—without which it is almost impossible to handle quality and cost.
  • Non-standard data: Providers have to submit information in different formats to different payers, developing a massive administrative burden.
  • Restricted access to capital: Deficiency of capital is an acute problem that delays investments in the infrastructure essential to take risk, which also drives consolidation.
  • Inadequate infrastructure: Necessary systems—involving information technology—is costly and difficult to implement, and it needs significant change management.

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

“Providers must be capable to access administrative claims data in both the federal and commercial settings,” claims the white paper. “Without a whole picture of a population of sufferers, it’s virtually impossible to handle the cost and quality of a sufferer’s care. While few payers provide this data to clinicians, many do not.”

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

To reduce the barriers standing in the way of providers, AMGA suggests:

  • Data improvements: Congress should need federal and commercial insurance companies and providers to standardize data submission and reporting procedures, as well as to give access to all administrative claims data to healthcare providers.
  • Access to capital: Congress should develop a fund that enables providers to utilize income on a tax-free basis to invest in taking downside risk.
  • MACRA: For success under Alternative Payment Models (APMs), Congress shouldn’t penalize Advanced APMs if there are insufficient risk products in their regional markets, permit Medicare Advantage revenue to count in performance year 2019 toward meeting the Advanced APM revenue thresholds, as well as permit Track 1 ACOs to be eligible as Advanced APMs.

In accordance to AGMA, it’s imperative that Congress and the Department of Health and Human Services deal the hurdles standing in the way of the transitioning to value-based care sooner rather than later, or progress in moving away from fee-for-service could grind to a halt.


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