On Oct. 18, Chief Strategy Officer of OptumCare Brian Mathis spoke on the role of ASCs and specialists in value-based care at the Becker's ASC 25th Annual Meeting: The Business and Operations of ASCs.
Here is an abbreviated summary of the moderated discussion between Mr. Mathis and Becker's Healthcare Publisher Scott Becker. Responses are lightly edited for clarity and length.
Question: How many SCA ASCs are participating in value-based care arrangements at this time?
Brian Mathis: We have now gotten to a point of 50 percent of our surgical facilities have at least one value-based agreement in place and at least 25 percent of them have two. All of those agreements are with the top one or two payers in the market, so it is very material.
Q: What do those value-based agreements look like?
BM: What they look like is a broad spectrum. It's everything from the traditional total joint bundled payment where you have the risk component covering 30 days pre- and 90 days post-surgery. We also have markets where we are engaged with specialists that have sub capitated agreements with risk-based groups. We look at how do you apply incentives to the surgeon based on site of service and I would say that is the most common form we see.
For a payer, the best thing they can do to get value out of the ASC industry is move more volume out of the hospital and into the ASC. It's not all the things around the episode of care, it's moving that site of service.
Q: What payers are SCA's agreements coming from?
BM: We focus on the top market share payers because that is what is most important to our physicians in terms of being relevant to considering changes to their practice patterns. This is generally the local Blue Cross plan and UnitedHealthcare. These payers also have the most to gain by putting these incentives in place and are willing to invest the time and resources to work with us.
Q: For independent surgery centers, what does it take to participate in value-based care and risk-based contracts?
BM: It starts with really strong clinical governance because it will all come back to whether you have good quality in your center. Do you have a good clinical governance system so people are actively managing the quality in your ORs? That is the true value of the product you are managing in the market. Do you have good data? That doesn't have to be overly complicated. We're not talking about blockchain and artificial intelligence, but do you have a good understanding of the metrics within your center and the potential of your surgeons. Do you understand and can you map out the potential of what your surgeons could be doing in your center? Could you present that solution to the payer or at-risk medical group?
Is there a willingness to change? Because people are going to have to change behavior if you are going to create that value. Any center can do those things, and do them very well, if it's well-run.
Q: Are there any value-based agreements that actually hurt ASCs?
BM: There are all these markets with accountable care organizations that are situated around the hospital systems. That's not because the hospitals provide the best value, but it's because they are big and they've got a bunch of people who can have a meeting with the payer and put together this ACO that the payer wants. What happens sometimes in those arrangements is that you create the ACO with the hospital system in a market, and suddenly the ASCs that aren't affiliated with the hospital system are left out of that network. So what we've seen in some cases is ASCs lose volume due to a well-intentioned effort by payers to drive care into the low-cost setting.
Q: How many physicians does Optum employ? What is the philosophy around physician employment?
BM: If you get into our employed base of physicians, it's almost all primary care. There are specialists mixed into some of those groups. As we looked into how to expand our presence in the specialist arena, it's very much an alignment model and we think about governance and how to leave the governance, particularly on clinical matters, within the existing medical practice. We also want our partners to see us as adding value. We can add value in how we relate to payers and other groups.