Q&A with Matthew Hellinger and Ian Goldberger

Ian Goudberger
Main transaction advice
business advisory services
practical and transaction advice
lead practice
Kaufman Rossin

Value-based care (VBC) is championed by many members of the pharmaceutical industry as a better way to deliver care and services to patients. Matthew Hellinger, director of business advisory services at Kaufman Rossin, and Ian Goldberger, director of transaction advisory and transaction advisory leader at Kaufman Rossin, discuss the hurdles payers face and why they continue to make progress with VBC.

Pharmaceutical Executive: What are some barriers that make VBC adoption difficult?
Matthew Hellinger and Ian Goldberger: Technology infrastructure and adequate data analysts to manage medical costs and assess financing in relation to members’ risk scores and medical costs are challenges in the adoption of value-based care.

Additionally, there can be a large learning curve for providers. Many providers may not be familiar with the key terms that determine VBC’s financial performance, such as MRA, IBNR, discounts, etc.

It can be difficult to assess the quality of results for specialists. Currently, most VBC models are available for primary care, with only a few specialties, such as nephrology, having robust programs.

Matthew Hellinger
Director in business consultancy
services practice
Kaufman Rossin

VBC is a different model than traditional care, which some physicians may not want or know how to use. For example, VBC includes more contact moments with the patient or the use of care coordinators to offer patients the opportunity to discuss their medical condition in advance, to avoid redundant care that may not be necessary.

PE: How can providers navigate VBC payment models?
Hellinger and Goldberger: It can be challenging for individual providers to negotiate direct VBC contracts with payers. They may need to work through an Independent Physician Association (IPA) or Managed Services Organization (MSO) that has the infrastructure and knowledge to help them adopt VBC. In these models, providers will typically have to pay the IPA or MSO for access to their systems and knowledge.

It may be useful for healthcare providers to engage an experienced professional advisor who routinely works within the healthcare system to help them assess the feasibility of moving to a VBC arrangement.

PE: How will providers choose which models work best for them?
Hellinger and Goldberger: One of the first steps for healthcare providers is to assess the current member pool and determine if they are open to a VBC care plan. They also need to understand which VBC payers operate in their geographic area.

Which model best suits the provider depends on the provider’s current membership performance. When discussing with a partner (health plan, IPA, or MSO), it is advisable for a provider to request and review data to align on what level of risk makes sense for them (global risk, shared risk, capitation only, quality bonuses, etc.) . .).

For example:

  • If members are usually profitable, a risk relationship can yield higher revenues
  • If members are not as profitable or are experiencing shortages, providers may be better off with a pure capitation model without risk, or remain on a fee-for-service basis.

PE: Will it be necessary for these companies to adjust their strategies to remain compliant?
Hellinger and Goldberger: Yes groups should retain well-trained legal counsel who are knowledgeable and knowledgeable about CMS regulations for value-based healthcare contracts and operations. The space is relatively new and nuanced; therefore, CMS will routinely make changes to reimbursement and documentation processes that impact financial results.

Healthcare groups must understand the proper documentation requirements to be accurately reimbursed for their members’ health conditions.

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