Shared-Risk Success for Specialists? Cater to Your Primes



“Tom” he said, “If it keeps me in the O.R. it’s good, if it keeps me out it’s bad.”  “Good,” he said gesturing to right, “bad,” he gestured to his left. “That’s all you need to know.”


Such was the wisdom imparted by my then new orthopedic partner when I asked him how we could best collaborate.


So I spent the next 15 years sending him the joints and the breaks and treating the other stuff myself.


Going forward today, he’s going to face some hard choices.


MACRA and MIPS have forced fee-for-service primary care clinicians to focus on data collection and submission rather than provision of actual medical care.


More patients per time period, more documentation per patient, less clinical time per patient.


Most routine problems are going to get sent upstream to specialists for management—nothing personal; it’s just the math.


And these are definitely not the conditions that’ll keep my partner in the OR.


As an orthopedist or other specialist, what are you to do?


Screening referrals for need, hiring an intake PA, putting more hours in the office . . .


These are often the specialists’ office tactics to adjust to the brave new world—you’ve seen (and maybe implemented) them already.


Those tactics might keep you in the OR, but at the cost of higher overhead, greater risk and much less overall patient satisfaction.




You could collaborate with your referral sources. Meet with those primary care clinicians and set up systems so they can prescreen your referrals for conditions you want to see and back them up with algorithms for those you don’t.


Of course, if your primes are paid exclusively fee-for-service they won’t really work with you.  Primes are now time slaves, pure and simple.


Without the buffer of procedural income which you enjoy, they have to be.


But if they have a managed care component with even a little risk-share, you can cater to that. Emphasize the benefit to their risk pool performance as you create systems that will benefit you both, then watch those benefits spill over to your fee-for-service lines and generate value for everyone—specialist, prime and patient alike.






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