MGMA’s Andrew Swanson on Innovation in Healthcare

Expert Interviews

Andrew Swanson, VP of Industry Insights, with Medical Group Management Association (MGMA), provides us with his perspective on how COVID has shaped the healthcare landscape, who is driving innovation in the field, and why value-based care puts the patient in control of their health.

What innovations in the last 1-3 years do you feel will permanently change the healthcare industry and why?

Telehealth reimbursement staying on par with in-person visit reimbursement will permanently change the healthcare industry. This pandemic-driven regulation change seems like it will remain in place over the coming few years and should drive providers to embrace telemedicine more entirely and offer these services to a broad patient base. If advances to medical licensing, credentialing and other related items tied to providing care from a distance also change, work from home providers or providers across state lines – and even globally – could help ease the scarcity of providers. The advancement of analytics, particularly the relationship between financial and clinical data, will help further advance value-based care and move us further along the continuum away from fee-for-service. Technology advancement in combining and visualizing information and staff expertise in using analytics will make this innovation lasting and achieve the goal of reducing the overall cost of care while steering payments to the appropriate player in our health care system.

Who (organizations or people) are the most meaningful disruptors in healthcare today and why have others failed?

Healthcare leaders in active practice, both physician and administrative, are the common denominator of innovative health care. There are plenty of disruptive organizations that bring change to our landscape but don’t have the leadership to drive a compelling vision for change in our industry. When the marriage of a good idea is fostered by agile people, then true change comes in our industry. Telemedicine wasn’t adopted overnight in March 2020 because a technical platform made it ideal – it was the collection of administrative and care providers who could only serve their customers through those channels that made it successful. Nobody argues that value-based care is a good thing. But only organizations who have agile, committed people, working the existing systems and processes in new ways, have been able to make it successful in all their endeavors (improved clinical outcomes, lowered total costs, and kept revenues at or above previous norms).

What areas of healthcare do you think are most in need of change?

Payment methodology, which is an excellent way to say everything about how we deal with money in the US healthcare system! Standardization across payors in clinical quality measures drives more accessible prior authorization standards, decreasing time and effort to provide care, reducing costs for both the practice and carrier. The incongruity between care provision and payment (i.e., fee for service, not fee for outcome) left unaddressed will not get us to total systemic cost reduction. So, if payment is tied to well-managed populations, intervening when appropriate with the right level of service, we’ll get to total cost reduction. But the payment methodology doesn’t reflect that motivation today, so we’re not incenting the right behavior on the part of providers. It is all our responsibility to own that change and have a healthcare system (payors, government, integrated system, medical practices, providers and administrators) working together to realize that vision.

What does value-based care mean to you? Can you provide us with some examples in action?

For me, VBC is our healthcare system’s way of pushing the public to manage their health with the guidance of a primary care provider, better than in the past. Encouraging preventative care, dealing with acute care as early as possible and keeping the lines of communication open between physicians and patients to achieve optimal health. Inside healthcare, we talk about this in the form of risk-bearing and payments. However, at its foundation, it’s about the patient’s responsibility for their health and endeavoring a mindset change in Americans to utilize healthcare differently. Anecdotally, some ACOs are really taking this seriously. In the Chicago market, Advocate has long been on the forefront of community care, extending their reach into underserved communities to identify health issues early, which improves the lives of the people they serve and keeps their care costs better in control. I’ve seen a decentralized primary care group serving the greater Denver market partner with specialists in a non-employed model with the goals of better care at reduced costs. And provider networks with health plans like Geisinger and Kaiser have long learned about the relationship between data sharing on both sides of the business to improve the cost of care.

What are the biggest challenges and obstacles to making your vision of a value-based care future a reality?

There are numerous, to be sure, but two large ones trump all the smaller ones in my estimation. The first is showing a model in a new payment methodology similar to a wide variety of groups that will prove to them that VBC and payments will keep them at least afloat financially. The second is demonstrating that it is also clinically positive for their patients and communities. The first is something MGMA is working on with a variety of other partners to take existing patient panels and working forward to show what type of financial results might be achieved depending on a variety of payment methodologies groups might employ within value-based care frameworks (partial risk, bundled payments, partial or full capitation, etc.). The second need is partially on insurers to come to the table with transparent data that marries the clinical treatments and costs of those treatments. Heretofore, payers have been unwilling to share the right data from a different perspective at scale to prove that these approaches are suitable for patients too.

Where do you like getting your industry news from? Which industry thought leaders do you listen to and why? Larger publications and aggregators like Medical Economics, Modern Healthcare and Beckers are always good to stay on top of the headlines. I tend to listen to thought leaders who are more present than future-minded because I find the future in healthcare to be slower to come than in many other industries. I listen to MGMA’s advocacy leader, Anders Gilberg, to get a pulse of what’s happening in Washington DC. I tend to watch what Amazon, Walmart and CVS are doing in the medical group practice space because those organizations tend to do things a certain way and they often make those ways successful! I also follow large health systems, and to a lesser degree, payers, as they are the prominent employer of physicians in the US, and that is a driver of how all health care is delivered.