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In this first part of a two-part series, we identify financial opportunities that can lead to improved patient care outcomes. In the second part of the series, we will weigh the considerations of developing an effective return on investment (ROI) plan and the components necessary for success.

Few would argue with the assertion that healthcare is hovering around crisis levels in the United States. The COVID-19 pandemic levied a disrupting ripple effect on patients and their caregivers. Working in pandemic conditions has resulted in levels of provider burnout that have not previously been experienced, and nurses are leaving the profession in large numbers. 

Additionally, with the advent of technology, patients are savvier about their healthcare and demanding more of their care teams. Today’s patient expects a more personalized care experience that includes two-way communication, accessibility, and a convenient location that fits their preference. 

Providers strive to deliver the highest quality patient care yet are increasingly tasked with doing more with less as budgets are often trimmed and clinics are often understaffed. America’s rural providers have been hit particularly hard with hospital closures and staff shortages while serving a more uninsured demographic than their urban peers. They are more likely to live below the poverty line and rely more heavily on the Supplemental Nutrition Assistance Program. [Source: NRHA]

According to a recent report published in Becker’s Hospital Review [Source: Becker’s], healthcare expenses declined in July 2023 but not by enough to offset revenue losses. Despite the decrease in costs, hospital systems, clinics, and providers still faced the reality that financial performance worsened.

Unrealized revenue streams

A first and logical step for provider organizations to address when considering financial solvency is to look for ways to cut expenses. While these decisions are difficult to make, it can be easier than developing or exploring new revenue opportunities – particularly when a prospect involves risk. However, with a growing emphasis on shifting from a fee-for-service model of care to a value-based model of care, organizations are positioned to consider the financial upsides of value-based care.

The Medicare Care Shared Savings Program (MSSP) has historically been optional. In 2021, however, the Centers for Medicare & Medicaid Services (CMS) established a goal to have 100% of Original Medicare beneficiaries and the vast majority of Medicaid beneficiaries in accountable care relationships by 2030 as part of a strategic refresh. [Source: CMS] The reasons for the refresh and pivot to value-based care are many, including the nation’s aging population and the solvency of the Medicare Hospital Trust Fund. Yet, shifting from fee for service to fee for value has the potential to realize previously untapped revenue streams while minimizing costs associated with care gaps and unnecessary procedures, as well as emergency department visits and hospital admissions. With a team-based approach, the entire team works at the top of their licensure, helping to alleviate the demand on the physician, who can spend more time with patients with the highest needs, resulting in a collaborative continuity of care.

Implementing value-based care methodologies, using a team-based, preventative care approach that helps to minimize the demand on providers, requires change across the spectrum of a healthcare organization. Some argue that MSSP can be a pay-to-play environment because there are costs associated with participation. Yet, the outcomes are proving to improve the financial bottom lines of participating providers and also help to enhance the patient experience and improve patient care outcomes.

3 Key Takeaways from MSSP Participation

Providers who participate in the MSSP have the assurance that the program is effective and helps to highlight areas of additional care opportunities, which result in taking advantage of previously untapped revenue sources.

1. New population health revenue: By ensuring complete and accurate documentation, providers are able to unveil previously untapped revenue opportunities. The Annual Wellness Visit (AWV) is foundational to value-based care and a pillar of MSSP participation. This preventative visit can lead to early disease detection and uncover opportunities to enroll patients in chronic care management, advanced care planning, and other preventative programs. Signify Health client data shows that top-line revenue per practice is between $115 and $160 per AWV.
2. Downstream revenue: Preventative and wellness services help healthcare teams identify care gaps. These gaps and previously unidentified concerns can be uncovered during the AWV. With standardized workflows and placing an emphasis on quality measures and accurate documentation, healthcare teams can discuss screenings, including mammograms, colonoscopies, and other appropriate interventions that can lead to improved patient care outcomes. Downstream revenue may come from initiating the AWV. 
3. Share savings revenue: Providers who participated in the 2022 MSSP performance year collectively earned more than $2B in shared savings. [Source: NAACOS 2022 Medicare Program Results] Although MSSP participation does not guarantee shared savings, it is only possible to achieve shared savings by participating.

Signify Health’s team of accountable care experts, including 340B Drug Discount Program specialists, provide the education and training, award-winning technology, proven value-based care workflows, and the scale for any organization to be successful in an accountable care organization (ACO). In the second installment in this series, we will delve into strategies and customizations for effective ROI plans to ensure ACO success.

To learn more about ACO participation with Signify Health, contact us.