The shift to value-based payments, especially capitation, will bring about changes across all clinical settings. One of those settings that has received relatively little attention to date is how the specialty office of the future will need to adapt in order for specialists to practice successfully and efficiently in a world with a mix of fee for service payments (albeit with more accountability for outcomes and widespread pay for performance) and global payments (whether via an ACO-type arrangement within PPO benefit plans; or capitation under an HMO product).
To date, the focus of all payers (Medicare, Medicaid, and Health Plans) has generally been on primary care, with a variety of (often conflicting) reporting requirements and pay for performance programs focused on both preventive and chronic disease care/. Primary care physicians have struggled with these requirements and the increased workload they generate and their response has largely been to either sell their practice (historically to a hospital-based system; of late increasingly to a Health Plan) or to contract with an entity that helps enable the needed transformation. Specialty practices have more generally stayed in relatively pure fee for service arrangements and focused their energies on maximizing practice efficiency within that payment model, whether they remain self-owned, sell to a hospital system, or (increasingly of late) sell to a private-equity-backed entity (the latter whom in turn typically focuses on further ramping up fee for service revenue).
The missing element in all the above is the relative lack of engagement with and transformation of the practices of the physicians who are most capable of managing the increasingly complex clinical care of patients with moderate and especially severe forms of chronic diseases. Two of those conditions (COPD and CHF) are the top causes of preventable hospital admissions in the Medicare population, and both those diseases, in their more severe form are not easily managed by primary care physicians due to the evolving drug complexities as well as the need for expert allied clinical staff.
How to navigate the needed transitions in specialty practices from purely episodic and transactional to continuous and coordinated requires an understanding of the current gaps and needed solutions – and characteristics of a preferred partner who can deliver on those.
The relative dearth of specialty-led comprehensive clinical management of these patients is due to the historically unbillable work in historic fee for service payment mechanisms. What we urgently need are parallel changes in both the type of care (comprehensive, coordinated, ongoing, proactive) and the revenue flows (under both fee for service and capitation) that support the needed work.
This is where enabler companies like HBox come in—bringing to physicians a turn-key suite of products that deliver on both those fronts: chronic care enablement, and compliant incremental revenue generation via appropriate use of the full range of approved codes: Remote Physiological and Therapeutic Monitoring (RPM, RTM), Chronic Care Management(CCM), Principle Care Management (PCM), and Transitional Care Management (TCM) – which collectively enable payment for previously unbillable activities critical to successful management of patients with serious chronic diseases.