The Tipping Point

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**Disclaimer: All opinions and ideas expressed in this article are solely mine and none represent a recommendation or should be viewed as advisement of any kind to anyone to do anything.*

Policy Pulse

The Moment Has Arrived

The average clinician is going to start feeling it. Not just hearing about it in a conference or reading about it on Linked In, but actually experiencing it in how they care plan, how they interact with patients, and what’s expected of them.

And for healthcare practice owners, this is no longer a future consideration. The pivot is now. Those who don’t transform how they deliver care will not survive the decade.

So what changed? Why now?

Four forces have converged:

• More data — more usable, more comprehensive, and more actionable

• Data insights built for the end user, not the analyst

• Greater interoperability across systems and settings of care

• Digital health tools that put real power in the hands of the healthcare consumer

The Only Lever That Bends the Cost Curve

Let’s be honest about where we stand.

CMS drives healthcare policy in this country, particularly since the Affordable Care Act created the CMS Innovation Center and enabled rigorous testing of what actually improves outcomes and lowers cost.

And the headwinds are real: high-cost medications, heavy use of acute care, expensive new treatments, and inflated reimbursement rates for non-time-based procedural services. None of that is going away on its own.

The Innovation Center needs time to test and find solutions that scale. Those who aren’t being realistic about the time this takes are taking the wrong approach to appreciating how enormous the task is.

There are really only two meaningful levers:

• Value-based care payment models and care delivery structures

• Biosimilar drugs

Biosimilars are relatively straightforward. Value-based care, on the other hand, is all-encompassing. It also often triggers eye-rolls and sighs. I understand the skepticism. But nothing else is capable of bending the cost curve.

What Happens When the Rules Change: A Real Example

The best way to understand value-based care is through how it changes traditional incentives inherent in fee-for-service. When incentives shift, behavior follows.

Take the Transforming Episode Accountability Model (TEAM). Hospitals are held accountable for every healthcare dollar spent in the 30 days after a patient is discharged. When the norm is responsibility for the stay itself (and a readmission hit for certain diagnoses captured in the Hospital Readmission Reduction Program) and essentially nothing starting the day of patient discharge, this is a big deal.

What should a hospital do when their wallet is on the line the moment a patient walks out the door? Here are some big levers if they want to at least prevent owing CMS money.

1. They assess actual, accurate patient function and safety before hospital admission and identify real support systems from day one.

2. They mobilize patients aggressively. Mobility reduces inpatient post-acute stays, the single biggest driver of episode cost overruns. The loss of physical power that happens in acute care stays without a medical necessity for bedrest is almost unforgivable. (It’s one of the hills I’ll die on.)

3. They partner with home health agencies and outpatient PT/OT providers (including OP providers that make home visits) that can begin treatment within 24 hours of discharge.

4. They invest in discharge planning teams who can train patients, communicate across settings, and set expectations with post-acute providers.

5. They scrutinize IRF placements. The cost of inpatient rehab often exceeds the cost of the hospital stay itself. No meaningful functional change? The patient shouldn’t be there.

6. They manage SNF throughput tightly. Many patients can move through a skilled nursing facility in 5–10 days when the episode is closely managed, realistic and appr.

7. They hire care navigators with deep expertise in Medicare payment policy to be the connective tissue across the entire care journey.

My team and I were doing all of this in 2017 and blowing away expectations. We were improving patients’ lives and helping them achieve a long-term successful care journey. We focused on the big picture and insisted everyone who touched our patients did the same.

We were rare then. The difference now is that the tools, the data, and the policy architecture are catching up to make this the standard.

What We Learned Building This in 2017

When my team supported BPCI-A, CJR, and MSSP patients through acute and post-acute episodes, we had something most health systems didn’t: good data, near real-time. ADT feeds. A risk-stratified dashboard. A vendor who integrated multiple data sources into a proprietary risk score that kicked in the moment we identified a patient through concurrent coding. A team of skilled and trained clinicians inside the hospital and embedded in post-acute sites of care working to help successful navigate patients through successful, safe care journeys and help them get back home and remain there.

We stratified. We shared. We did deep dives into patient journeys with stakeholders across the continuum. We saved money for CMS by improving quality, reducing unnecessary post-acute utilization, and setting patients and families up for long-term success. We earned shared savings by reducing avoidable and unnecessary spending. We improved the patient experience and their outcomes.

When I left that health system after 20 years and multiple roles, I realized this:

We were way ahead of the game. 

Not because of luck. Because we made major investments in people, data, interoperability, and analytics, and because we had the C-suite buy-in to see it through.

A movement has been building. If you haven’t experienced it yet, that’s likely because of your employer or, if you’re an owner, because you’ve chosen to remain entrenched in fee-for-service. And you yourself may not have made the deliberate decision to learn how the pieces all fit together and how VBC works. It’s not too late!

Straddling fee-for-service and value-based care is genuinely hard. So just expect it. For most, it’s a multi-year transition. But the direction is set. Invest in change or be disrupted.

Digital Health: The Accelerant Few Saw Coming

Digital health tools have mostly existed as employer-sponsored add-ons and parallel to healthcare, not integrated within it. Your employer offers free access to a digital health point solution. A small percentage of employees opt in. Those who need real clinical care hit a wall: the digital tool doesn’t talk to the PT clinic. The PT doesn’t have access to the platform. The consumer experience is fractured.

That’s about to change fundamentally.

Enter the ACCESS Model

For the first time, a digital health vendor will be able to submit to become a Medicare provider and bill under Medicare Part B. CMS is betting that integrating digital health into mainstream medical care (rather than keeping it as an employer add-on) is a game-changer.

CMS isn’t writing blank checks for billing for digital health, however. ACCESS Model participants must demonstrate avoided duplicate care management spending and improved outcomes using well-established measures. Underperform? Receive as little as half the payment.

They’re also requiring data sharing between digital health providers and the patient’s primary medical provider managing their chronic condition, and requiring those providers to ingest and share data back. In return, providers can bill a co-management code for collaborating with the digital health provider and data sharing. It also opens up the option for reducing their own investment in patient engagement tools and care management staff, depending on their partnerships with ACCESS Model participants and clinicians like physical and occupational therapy practices and behavioral health practices.

And here’s the detail that might seem minor but isn’t: CMMI is allowing ACCESS participants to waive the co-pay. For a repeated service like care management, the friction of getting verbal consent for cost-sharing is of a common dealbreaker. Many practices already provide care management without billing for it because of this friction alone.

The End of Healthcare’s Information Monopoly

For decades, healthcare operated on information asymmetry. Providers knew things patients didn’t.

The system was built around that imbalance, and, in many ways, depended on it.

That era is ending.

Patients are done tolerating what they once accepted:

• Months-long waits for an appointment

• Phone-only, 9–5 scheduling

• Urgent care as the default option for everything

• Repeating their medical history at every visit

• Paper forms and faxed records

• Weeks of waiting for test results

• Cookie-cutter advice and treatment plans

• No follow-up, no proactive outreach, no real continuity

The bar is no longer set by healthcare. It’s set by the best consumer and AI experiences people have everywhere else, such as in banking, in travel, in retail. Patients now expect the same in their healthcare.

Data availability, digital health, single-touch data sharing, and easy identification of low-value providers are creating a monumental shift. Good data and value-based care agreements are the tools that allow forward-thinking providers and organizations to get ahead of it.

The Call is Clear

This isn’t doom and gloom. It’s a wake-up call, and there’s still time to answer it on your own terms.

For Clinicians

Understand what value-based care actually requires of you. It’s not just a billing change — it’s a different relationship with your patients, their data, and their care journey. Learn the incentive structures. Know what programs your organization participates in. Understand what metrics matter and why. Your patients will be more engaged, better informed, and less forgiving of experiences that don’t meet modern expectations. That’s not a threat. It’s an opportunity to practice at the top of your capability.

For Owners

The window to lead this transformation is open. Straddling fee-for-service and value-based is the reality for a while. But don’t let that stop you from building toward a future that isn’t entirely dependent on volume. Invest in data infrastructure. Invest in care navigators. Partner with digital health vendors who are entering the Medicare ecosystem. Build the care teams and processes that make your organization indispensable in a value-based world.

The iceberg is visible. The tools to change course exist. The only question is whether you’ll act before or after the collision.

This Week, Try This

Check out this article by my friend Alex Bendersky! 👇️ 

*Disclaimer: All opinions and ideas expressed in this article are solely mine and none represent a recommendation or should be viewed as advisement of any kind to anyone to do anything.*