Providers, insurers join to share risks, savings

HANDS-ON CARE: Dr. Nathan Beraha, medical director at Anchor Medical Associates, examines 9-year-old Cailyah Correia at Anchor Medical in Lincoln. / COURTESY LIFESPAN
HANDS-ON CARE: Dr. Nathan Beraha, medical director at Anchor Medical Associates, examines 9-year-old Cailyah Correia at Anchor Medical in Lincoln. / COURTESY LIFESPAN

As medicine evolves from “fee for service” to proactive, patient-centered medical care, primary care physicians and hospitals are affiliating with insurers to share risks and rewards.

Affiliations, such as the recent one between Lifespan and independent physician group Community Physician Partners Inc., are becoming the norm within the health care industry. Interested in working with all major insurers, this affiliation is headed toward becoming an accountable care organization, said Marc Proto, Lifespan’s vice president of contracting and payer relations.

The federal Centers for Medicare & Medicaid Services are pushing ACOs, which require robust PCPs to succeed, says Dr. Michael Fine, a family physician and former Rhode Island Department of Health director.

A shift in federal law to value-based care that holds practices accountable for health care’s quality and cost will, said Dr. Nathan Beraha, Anchor Medical Associates’ medical director, “be copied soon by the rest of the health insurance world.”

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Rhode Island’s Office of the Health Insurance Commissioner also expanded commercial health insurers’ quality-based payment model, which will continue to drive quality and cost-containment measures, he said.

But more patients don’t necessarily bring more savings, said Proto. While these agreements need a large patient population, patients must be managed properly to generate savings.

Lifespan, Blue Cross & Blue Shield of Rhode Island and more than 20 physician groups saved almost $6 million in 2014, during the first year of a three-year shared-savings initiative, Lifespan reported.

Such savings are what all partners in health-network affiliations are after, including the one between Lifespan and Community Physician Partners, which includes Anchor, Medical Associates of Rhode Island Inc., University Internal Medicine and University Medicine.

Other practices in the state have also forged affiliations, including that of Coastal Medical – itself an ACO – Lifespan and Blue Cross.

In partnership with Rhode Island Primary Care Physicians Corporation and South County Health, Care New England established its ACO, Integra Community Care Network; Prospect CharterCARE system, which includes Roger Williams Medical Center, Fatima Hospital, a skilled nursing facility, an expansive IPA and CharterCARE Medical Associates, provides coordinated regional care.

Community Physician Partners has “the highest-quality practices in the state [with] phenomenal doctors,” who see their patients in the hospital, said Fine.

Remaining independent, CPP’s practices have discretion in referring patients to specialists and hospitals, said Beraha. Short of CPP partnering with the Mayo Clinic, Lifespan offers the best care available for their patients, he said.

“Lifespan’s referrals have to be earned,” said Proto, noting that care must be necessary, in the right setting and at the right time.

Dr. Michael “Mickey” Rosenberg, a recently retired osteopathic family physician on Providence’s East Side, said he anticipates “pressure to keep patients within the Lifespan risk pool. If you refer patients out … you’ve lost the ability to control costs.” Physicians and hospitals need these arrangements to survive, he said.

Will small practices be devoured?

“I think payers here are pushing folks … to be part of a larger network of care,” said Proto. Small practices can’t afford investments in infrastructures of sophisticated electronic medical records and broad-based patient-performance management.

Consolidation is already underway; some 75 percent of PCPs locally are employed by hospitals, physician groups or community health centers, Fine said. However, micro-practices, with no staff other than doctors, who provide same-day access and 24-hour, on-call service for patients, intrigue Rosenberg and Fine.

“They may have a secret sauce,” said Fine.

But the jury is out on whether the new affiliations are sustainable.

As insurers incentivize providers to achieve better health outcomes and lower total costs of care, they shift risks to providers, said Proto.

“There has to be funding … from insurance companies to support and enable infrastructures to make value-based care sustainable,” he said.

“[There’s a] fear of taking on too much risk… We’re asking people to play in the sandbox … of insurers,” agreed Dr. James Fanale, chief integration officer for CNE and Integra.

“I worry… who decides what’s quality care… Is it totally based on [national standards]? It’s not the ‘evil empire,’ but it has the potential to be,” said Rosenberg. •

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