Sharing the savings

Establishing a value-based care delivery model can present numerous obstacles for medical practices. Provider buy-in, accurate data tracking and payment system challenges can all impede adoption. To ensure they get the most out of a shared savings program, practices need a sound strategy to align providers and other stakeholders.

Such was the case with Shore Physicians Group, Somers Point, N.J., which was founded as a for-profit entity in 2012, as an alternative for physician employment with Shore Medical Center. The parent company for both entities is Shore Health System, which also oversees Shore Quality Partners, the clinically integrated network (CIN) that links the practice’s employed physicians with independent physicians. It’s through SQP that the group negotiates with payers on shared savings contracts. 

Culture helps foster growth

During the past seven years, Shore Physicians Group has grown from just five physicians to 87 in 11 offices at the end of 2018. Although located in a small beach community, the group offers care in 16 specialties to residents who might otherwise drive to larger tertiary care centers in Philadelphia or New York City. The practice’s payer mix — 50% Medicare, 15% Medicaid and 35% commercial — made it possible to join an accountable care organization (ACO) and participate in a shared savings program. In addition, its compensation model is determined by wRVUs, quality and shared savings.

In 2012, Mark Stephens, chief administrative officer, Shore Physicians Group, was hired to initiate a physician alignment strategy. “One of the things that was important to us when we got started was the notion of physician governance,” Stephens says. “The hospital and health system were looking to begin to employ physicians, and it was my preference that we do it in a way that would help us create culture from day one.”

This guaranteed that the physicians, not administrators from the hospital and health system, would hold governance and leadership roles in the practice. It also enabled physicians to create a culture in which they focused on quality, cost efficiency and shared savings. These factors laid the groundwork for the practice’s bonus plan and formula.

“We knew that the providers had to be involved in developing the formula for the distribution,” Stephens emphasizes. “It couldn’t just be done by the administrators; we had to have the physicians’ buy-in, and we also wanted to include the employees. The staff are so critical to how we do this … so we had to have some of the money trickle down to the employees.”

Shore Physicians Group’s shared savings bonus was designed to reward providers (physicians, physician assistants and nurse practitioners) in terms of quality and financial efficiency, as well as its staff for their care contributions. To gain acceptance and alignment, the practice asked its compensation committee to determine shared savings distribution.

According to Jennifer Colvin, manager, clinical quality and revenue enhancement, Shore Physicians Group, “It was really key that we had representation from our entire group on this committee to create a shared savings distribution that would be accepted,” she notes. “We had a lot of committee members who challenged and prepared us in those committee meetings so that when we were ready to roll it out to the group, we were very prepared.”

The committee helped develop a custom formula based on three factors that would determine bonuses:

• Cost (40%)
• Quality (30%)
• Citizenship (30%)

Cost

Shore Physicians Group made this category the largest piece of the distribution formula because cost drives shared savings. The practice’s cost performance stems from risk adjusted per member per month spend, and outliers are not included. “Anybody over $100,000 was excluded,” Colvin says. “If it was less than the group’s average risk adjusted per member per month spend, that provider received 100% of their costs. If the risk adjusted per member per month spend was greater than the group’s average risk adjusted per member per month spend, they received 50% of their costs.” 

Quality

This metric is set by the U.S. Preventive Services Task Force and based on Healthcare Effectiveness Data and Information Set (HEDIS) quality measures provided by Blue Cross. In 2017, the practice was assessed on seven quality measures:

• Adults’ access to preventative/ambulatory health services
• Breast cancer screening
• High blood pressure control
• Diabetic eye exam
• Diabetic HbA1c testing
• Diabetic medical attention for nephropathy
• Depression screening PHQ9.

 
The goal is to reach the 90th percentile, which guarantees higher shared savings. A provider must reach this level in four of the above categories to receive 100% of the quality bonus. If he or she attains this level in three categories, it’s 50% and two categories is 25%.    

Citizenship

Citizenship is the practice’s most basic formula; it’s used to identify and then improve care gaps with the care coordination team. Scores are determined by the providers’ willingness to meet with Shore Physicians Group and Shore Quality Partners representatives to review data and quality metric performance, for which they receive credit.

Results

In July 2017, the practice’s primary care physicians were only hitting two of the quality metrics at the 90th percentile. To receive bonuses and earn back money from 2016, they needed to attain the 90th percentile in four metrics. By December 2017, the physicians reached the mark for all seven metrics. What changes were made during the second half of the year?

In the cost category, the practice zeroed in on cost and utilization and other per member per month drivers. First, they targeted their high-risk patients. “I like to say that we love them a little bit more; we paid more attention to them,” Cindy Miller, director, network development, Shore Physicians Group, states. “The care managers knew who was stratified as sicker and really focused on them.”

The staff also focused on contacting ghost patients — those who hadn’t been seen by the practice in a while. This all resulted in a change from inpatient to outpatient care. Similarly, they removed patients from their roster who had left the area, were seeing other primary care physicians or were non-compliant by not showing up for appointments or failing to take their medication.

Next, the practice eliminated some of the barriers to care coordination by hiring four full-time-equivalent (FTE) care coordinators who were each assigned a set number of providers. They further addressed risk scoring by providing coding training for providers, assigning each provider a biller who specifically reviewed his or her coding and obtaining additional help from outside coders.

Finally, the practice reduced its emergency department utilization and improved its in-network utilization by convincing patients to use its multi-modality imaging center. By focusing on these cost drivers, the practice met its clinical quality metrics and reached full earn-back.

Yet, according to Miller, not every provider initially bought into every metric. The practice had to convince some of them about the value of the citizenship metric: “It seems like a no-brainer, but we had providers who wanted to be out the door at 5 o’clock, [and] did not want to review data and drill down on numbers because they’ve been doing it a certain way forever,” she says. 

Initiating monthly meetings with the care coordination team and quarterly meetings with the quality team helped address this issue. However, the desire for everyone in the practice to pull his or her own weight in meeting quality and cost metrics was an even bigger carrot.

As David May, MD, FACS, president, Shore Physicians Group, points out, the providers realized over time that there is much more that goes into population health than just their contribution. “Physicians do a great job of taking care of the patient who is in the office, but they really don’t understand that there are thousands of patients they’re not seeing every day,” he notes. “Initially, they thought the staff had no control over cost, then they realize that they can have some control over cost by utilizing our network in different ways. They start to understand that it’s a team that’s going to work on this and that the care coordinators, the medical assistants, our IT team is a crucial part of it.”

In the end, engaged providers and staff who work in unison can help enhance practice performance and improve shared savings distribution.