Maximizing the Benefits of Taking on Risk

When Congress eliminated Medicare’s sustainable growth rate formula earlier this year, many believed it meant, among other things, an increase in the number of accountable care organizations. For practices joining these ACOs, that means taking on additional risk.

How best to prep for that transition? Jeffrey LeBenger, MD, FACS, chairman and CEO of Summit Medical Group, New Jersey’s oldest and largest private multispecialty medical group, says practices need to start with a deep introspective look at themselves.

“They need to look at their leadership and their governance on the physician side,” LeBenger says. “They really have to have a mission statement of high quality and low costs. And they have to follow it.”

Talking from Experience

Two years ago, Summit Medical Group joined the Horizon OMNIA Health Alliance in New Jersey. The alliance is centered on value-based care and involves some risk sharing among partners.

Fortunately for Summit, which was incorporated in 1929, providing value-based care is nothing new.

“For us, it’s all about the patient; all about the member experience,” LeBenger says. “First and foremost, do no harm, and treat the patient.”

LeBenger explains that the key is creating an infrastructure for population health metrics, such as care management, navigation, opening urgent care centers—what he refers to as “extenditis,” which translates into physician extenders in skilled nursing facilities to manage your patients. And all of that is interconnected with a single electronic medical record; all knowing it is for the benefit of that patient, and to improve the quality metrics of that patient.

“What Summit Medical Group has shown is that we’ve met every quality metric in the top quartile, and two years ago we saved 8% of costs across the board,” LeBenger says. “And this past year, even with bringing in 150 new physicians, we were still able to cut costs and be in every top quartile quality measurement with another 5%.”

A Cultural Mindset

LeBenger explains that because of that infrastructure, that integrated approach, there was essentially no difference in how Summit took care of patients after joining the Horizon OMNIA Health Alliance. For physician on the outside, in an IPA or even in a hospital environment where, according to LeBenger, there is no integration of medical care, working as one can be a challenging proposition.

“We’ve been doing this for 85 years,” he says. “When a doctor on-boards to the Summit Medical Group, we tell them, ‘It’s okay if you don’t want to come, but if you come, then you have to follow certain processes that we set up across the organization.”

LeBenger says that process is built on transparency, fairness, honesty, and trust. Those are the core values, but one stands out above all the rest.

“The most important is transparency on how we operate,” he says, “so patients and physicians feel they are getting a fair shake.”

That mindset has enabled Summit Medical Group to “give birth” to Summit Health Management, a stand-alone company with a separate board of managers. And that, he says, is where the population health product resides.

“We feel that our model of management can be exported, in the way that we take care of the patient, about the patient experience, about getting the doctors to understand quality metrics,” LeBenger says. “And we feel that if you do the right thing and you set up the right services, economics do follow.”

Considering Costs

LeBenger agrees that physicians working in this type of risk-sharing model must become more sensitive to costs, but that the model can also improve the bottom line for the practice or medical group.

“So when you look at costs, what you look at is moving the care of patient to a less costly setting; to care manage that patient, so you don’t end up in a high cost setting,” LeBenger says.

He uses the example of a patient with congestive heart failure. There are simple care management questions that the patient needs to be asked. For example, do you need to sleep on an extra pillow? Or did you gain weight. Can you walk to make breakfast? The fix could be as simple as making a change in their medication regimen.

“That would avoid an ER visit,” LeBenger says. “It will avoid a hospitalization. And the average hospitalization costs $20,000. So there are absolutely processes you can set up that can save money for the organization.”