Direct Contracting (DCEs) - Build a Strong PCP Roster - Trella Health
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Blog

Key Considerations for Emerging DCEs: Building Your Primary Care Network

By Mimi Freleaux | April 19, 2021

The transition to value-based care in the American healthcare system has been a long time coming. And, although the Centers for Medicaid and Medicare Services (CMS) recently halted applications for their 2022 Global and Professional Direct Contracting payment model, the idea of risk-sharing payment models is still very much in play. For those considering creating an MSSP Accountable Care Organization (ACO) or Global and Professional Direct Contracting Model (GPDC) – whatever these may look like in the future – it’s critical that you have the right partners along the way. In a previous blog, we discussed why post-acute care organizations were important to the overall success of an ACO or GPDC. But what about the primary care physicians (PCPs) that fill your network’s roster? How do you identify the physicians that will help you meet and exceed your benchmarks?

Market Evaluation

The first thing to consider when building out your GPDC program is the market opportunity and services area of the physicians to recruit. When evaluating a market, it’s imperative to know the competitive landscape of other MSSP/DCE’s operating in that area including their PCP roster and preferred partners, performance (cost, quality, churn, etc.), and beneficiary penetration vs. eligible Medicare patients available for attribution, etc. Other things to consider are the PCP density compared to the total volume of Medicare patients in a service area, and the volume of “open” PCPs not participating with an ACO today as this will make recruitment easier.

Once you’ve identified your target market, it’s time to recruit PCPs that would bring a large network of attributed Medicare beneficiaries. To do so, you will need a Medicare-approved VRDC data source which includes 100% of all Medicare Part B claims. Ensure that data vendor calculates the CMS published MSSP ACO & GPDC attribution methodology and supplies relevant GPDC metrics to make informed decisions.

Historical Performance

Depending on the DCE Type, your CMS GPDC benchmark is determined by blending your participating physicians’ historical performance and the adjusted MA rate book. Understanding a physicians’ historical spend and what contributed to that spend by category for their attributed DCE beneficiaries is initial step when evaluating if they will help or hurt your benchmark. Use our Physician Scorecard Template to help evaluate prospective PCPs on the following metrics:

  • DCE-Attributed lives: How many of their FFS patients would be attributed to this clinician?
  • DCE Per Member Per Year (PMPY) Average Spend (Risk-Adjusted and Unadjusted): Of those DCE-attributed patients, what was their total historical spend?
  • DCE Per Member Per Year Base Cost: Of the average DCE PMPY total spend, how much of that was paid to the PCP?
  • DCE Hierarchal Conditional Category (HCC) Patient Risk Score: What is the average HCC risk score of their DCE-attributed patients?
  • DCE ER/Observation Utilization: How many of their DCE attributed patients went to the ER but were not admitted?
  • DCE Inpatient Utilization: How many of their DCE Attributed patients required an inpatient hospitalization?
  • DCE All Cause Readmissions: Of their DCE attributed patients, how often were the patients readmitted after an inpatient stay?  
  • Preventative Care Claims: Does this physician practice various preventative care activities and what is their experience level with each program?
  • Medicare Advantage Lives: How many MA patients do they see per year?
  • Current and Historical MSSP ACO Participation – Does this provider work with an MSSP ACO today or have they had experience with an ACO in the past?

With each of these metrics, you want to see how they stack up against others in their county. You want to recruit PCPs who have a good balance of room for improvement and good existing patient outcomes.

Bringing the Metrics Together

CMS incentivizes risk-sharing entities to improve the quality of a patients care at the lowest cost. While the metrics above won’t solely identify ideal PCP’s to target, holistically the metrics guide you to target the best clinicians that would set your organization up for success. Narrow down your candidates with these steps:

  1. Cost Savings: Once you’ve identified the PCPs with high counts DCE attributed beneficiaries, it’s time to look at their total spend and what contributed to that total spend. What is their average PMPY spend for their DCE patients? Is it higher or lower than the county average? Where are areas of improvement within the spend? Are their patients going to the ER or Inpatient more often or are they going to expensive facilities? What is the PCP’s average revenue per patient?  A low PMPY spend compared to the county MA rate book is likely an automatic shared savings win.
  2. Risk Score: Patients with higher risk scores typically incur more costs than lower-acuity patients. Use HCC risk-adjusted DCE metrics to help you truly compare physicians and identify ideal clinicians even if they are treating high acuity patients. Additionally, if you see a PCP’s with extremely low risk scores but relatively higher spend can indicate the physician is potentially not coding accurately – an area that you can likely improve.
  3. ER Visits, Inpatient Admissions and Readmissions: A PCP’s ER, Observation, Inpatient Admission and Readmission rates show how skilled they are at managing their patients’ conditions and avoiding unnecessary hospitalizations or emergency department visits. Both alternatives are very costly and choosing to partner with a PCP who knows how to limit avoidable readmissions will prove beneficial to your DCE.
  4. Preventative Measures: Knowing if a physician practices preventative medicine will help you understand the architect of their practice and where they are in the value-based care transformation. Typically, high preventative medicine PCPs are skilled at getting ahead of their patients’ needs to avoid hospitalization or emergency care – and thus at managing patient costs.
  5. Patient Growth: Is there a large disparity between the total number of FFS patients seen by this PCP and the number of DCE-attributed lives? If so, there may be an opportunity to increase the DCE attribution for this PCP over time. But make sure to analyze the metrics above for the non-attributed FFS population to ensure it’s in your best interest to do so.
  6. Create a physician value proposition: Now that you’ve identified your targets, utilize these metrics to create a compelling message on why that physician should join your program. We know that becoming part of a well-oiled risk-sharing entity will help them enter the value-based care world and build stronger relationships with their patients, but physicians like to see their own data and how it would specifically benefit them. Therefore, ensure consistent income above what they are making today while reducing administrative duties, and prove their patients will receive better care from the PCP having more time with them and additional care resources/programs that will, in turn, improve patient outcomes. It’s a win-win for everyone!

Predicting Risk

Embarking on a value-based journey requires a fair bit of up-front analysis; in order to reach your benchmarks, you need a balanced, robust roster of primary care physicians. The metrics we covered above will help you initially identify the PCPs most likely to help you reach your benchmarks and thus reduce your risk. Stop going in blind and using recommendations and connections as your primary source for targeting. We’ve seen it fail too many times.

For a more robust, automated way to predict risk and build out potential PCP rosters before you take on the risk, try Mosaic from Trella Health. Mosaic provides market-wide visibility into consistent, standardized quality and cost metrics across provider types to help healthcare organizations build high-performing partnerships—with confidence.

Request your demo of Mosaic from Trella Health today to learn how you can build the best risk-sharing roster to help you reach your goals.

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About the Author:

Mimi Freleaux

Mimi Freleaux, Solution Engineer

With over a decade of healthcare experience, Mimi’s passion is solving complex business strategy needs of her clients and helping transform organizations to value based care. Healthcare is deep-rooted in her blood as her great-grandmother founded Gwinnett Medical Center in Georgia (now apart of Northside Health System). Mimi’s healthcare journey started during her collegiate days at the University of Georgia, where she studied business and economics and served as an intern under the COO of the health system. Now living in Southern California, a pioneer region for value-based care, Mimi has a unique understanding of challenges facing the healthcare industry and keeping her finger on the pulse of tomorrow’s innovations.