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The Next Chapter of IDR: Trends, Metrics, and Strategies for Providers · Becker’s Healthcare Podcast

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  Hi, everyone. This is Chris Sosa with Becker's
• 0:01
  Healthcare. Thank you so much for tuning in
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  today's podcast of the Becker's Healthcare podcast series.
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  Today, we're going to talk about the next
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  chapter of IDR, trends, metrics, and provider strategies.
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  Joining me for today's discussion is Patrick Velleke.
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  He is the chief external affairs officer at
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  HaloMD.
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  Patrick, thank you for being here today. Pleasure
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  having me, Chris. Awesome. Well, Patrick, to kick
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  us off, can you share a little bit
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  about yourself and how you work in health
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  care? Yeah. Thanks. So I got my start
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  in health care on Capitol Hill. Worked for
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  a member of the US Senate, for a
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  number of years and then moved over to
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  the house side handling policy,
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  issues for for both of those members. I've
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  worked on the payer side on, advocacy issues,
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  worked in house for, Humana and then for
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  Anthem, which is now Ellevance.
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  I've also worked for the Federation of American
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  Hospitals, so I've sat on the hospital side
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  of the table, and most recently was with
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  with Envision Healthcare, a large multi state, multi
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  specialty medical group. Joined Halo, about two and
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  a half months ago. And, I'm really, really
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  excited to be,
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  bringing some of these IDR solutions to, to
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  clients on this side. Excellent. So, yeah, you've
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  been all over the place having, worn a
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  number of different hats. So, that experience, I'm
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  sure, comes in handy with your position now.
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  Yeah. I like to say, I I think
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  the only,
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  sides of the table I haven't sat on
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  are are probably pharma and med device.
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  So, yeah, I've either heard or sort of
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  put out, just about every angle on on
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  health care policy. So Oh, fantastic. Excited for
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  this discussion. Alright. So first question I have
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  to you is for you is simply we're
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  starting to see patterns emerge from early IVR
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  cases under the No Surprises Act.
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  What trends are you seeing in arbitration outcomes,
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  and what do they signal for providers moving
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  forward? Yeah. So the trends have been really
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  positive for providers and and facilities.
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  There's publicly available data known as the, CMS
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  public use files that detail the actual outcomes
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  from arbitration.
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  And they've shown consistently about an 80% or
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  higher success rate on the provider side of
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  the equation. Which means when providers engage in
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  the arbitration process,
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  they usually win. And they are able to
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  obtain
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  fair and sustainable rates through utilizing that process.
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  So, really, the messages
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  on that, Look, if you are thinking about
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  engaging the IDR process and concerned about out
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  of network reimbursement,
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  the IDR process might be a solution worth
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  considering.
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  Definitely good to know. Second question I have
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  for you simply, Patrick, is as finance leaders
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  plan budgets for the next year, what key
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  metrics or benchmarks should they be watching for,
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  to better anticipate IDR related revenue shifts? Yeah.
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  There are a lot of challenges coming down
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  the pike for facilities especially, but on the
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  provider side as well.
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  And, like, it's never been easy to run
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  a hospital, but I really looking at at
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  next year, there's some challenges that facilities are
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  going to have to get ahead of. You
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  look at some of the impacts of the
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  OBBBA,
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  legislation,
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  that will almost certainly result in some level
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  of increased uncompensated care.
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  You look at the potential sunset of the
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  exchange subsidies,
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  also likely leading to,
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  changes in coverage for, millions of Americans.
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  Facilities are are likely to see increased rates
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  of of uncompensated care and, increased rates of,
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  unfavorable
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  prepare mix.
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  So being aware of that on the front
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  end will, hopefully, if they are aware and
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  then start to look into the potential impact
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  for their specific facilities,
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  allow them to
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  identify the need to close gaps. And IDR
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  is one way that they may be able
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  to to close those gaps.
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  It'll also be important for facilities to understand,
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  their
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  sort of relationships with contracted provider groups. Most
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  facilities,
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  contract out for at least some of the
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  services that they offer within their four walls.
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  And a lot of those different service lines
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  are often subsidized. Right? Where the,
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  the physicians providing those services,
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  would be operating at a loss of just
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  on on revenue. Right? So the facility has
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  to make up that that delta through, a
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  subsidy arrangement.
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  Providers are also going to be facing some
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  challenges that could erode some of their reimbursement.
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  The Medicare vision fee schedule final rule just
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  came out on Friday. And it finalizes some
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  pretty significant reductions in practice expense, RBUs,
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  for facility based physicians.
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  So you may see some of these specialties
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  that are already seeking subsidy in order to
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  provide services,
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  come back in a couple of weeks to
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  months to say, hey, we need to talk
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  again about about more subsidy. So
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  facilities really, like I said, need to understand
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  those different risks and,
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  start to identify opportunities
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  to fill those holes or solutions for efficiency
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  and improvement of of their operations.
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  And the facilities that do that now are
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  going to be in a whole lot better
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  shape than the ones that do it six
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  months from now when some of those changes
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  are already taking place. So I I think
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  the real message here is there are real
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  challenges
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  that require
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  understanding and urgency to ensure facilities aren't negatively
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  impacted.
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  Certainly a lot to think about there. Thank
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  you so much for laying all that out,
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  Patrick. So based on your experience, how can
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  CFOs and revenue cycle leaders strengthen their negotiation
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  strategies with payers in light of these IDR
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  decisions? Yeah. One of the great things about
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  IDR and the NSA generally is that when
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  it was originally drafted, one of the key
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  purposes behind it was to encourage in network
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  arrangements that are sustainable and durable.
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  The idea is that you might go through
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  an arbitration process for several rounds, maybe couple
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  of months, between a a payer and a
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  provider or facility.
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  And that process ought to help both parties
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  understand where the economic equilibrium is. Right? And
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  if you are on either side of the
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  equation, you keep losing over and over again.
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  Let's say, an 80 of the time rate.
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  You start to understand, hey, it would be
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  a whole lot less expensive for me if
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  I were to just contract
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  at something approaching that rate. Save the fees
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  on both sides and reduce overall costs.
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  So,
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  really, behind the NSA is a mechanism
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  to help reach those sustainable long term arrangements.
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  It's a little discouraging that we haven't seen
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  that really take place yet. I think the
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  adjustment period is taking a little longer than,
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  most of us anticipated.
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  But
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  facilities especially, but provider groups as well, should
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  really be looking at the IDR process as
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  an avenue toward in network arrangements.
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  Folks shouldn't want to be on a network.
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  We should want to be streamlined and
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  and, you know, on a process that lets
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  both sides
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  be sustainable.
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  I'm hopeful that the IDR process will still
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  get us there, but that's really the way
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  that most folks ought to be thinking about
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  their engagement in the process.
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  It is not the last resort when negotiations
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  fall apart.
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  It's a tool in the toolbox toward finding
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  that sustainable equilibrium rate and demonstrating its validity
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  to drive toward a durable in network arrangement.
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  Do you think, the current
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  climate is pushing more organizations toward this process?
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  And have you seen a tipping point in
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  in this process? I think we're approaching it.
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  I think
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  the process is so consistently led to
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  a result. Right? Like I said, since the
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  public use files have started coming out, the
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  rate of success on the physician and and
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  facility side has been 80% plus. Yeah. That's
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  a pretty clear demonstration that the the more
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  reasonable offers here are coming from the provider
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  and facility side.
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  I I obviously, it takes two to tango
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  here. Right? It takes both parties coming together,
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  negotiating on a rate.
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  But I I I'm hopeful, like I said,
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  that the consistency and the outcomes,
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  will start to drive that consensus toward, hey,
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  let's network.
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  There are unnecessary costs in the system from
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  arbitration fees and and from the cost of
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  the process.
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  That's intentional. The arbitration process was designed to
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  be cumbersome and expensive
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  so that folks didn't rely on it, on
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  on either side of the equation.
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  If we wanna address some of those costs,
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  the answer is
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  get in network at the rates that have
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  been prevailing in the idea process. So there's
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  a lot of opportunity there. I think we
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  are, again, with with such a trend
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  and and consistency
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  in the direction of these,
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  you know, fair,
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  reasonable,
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  sustainable rates and and winning on the provider
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  side.
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  I'm hopeful we start to see some of
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  that transition in the networking
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  and that sort of leveling out of of
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  utilization.
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  Understood. Patrick, is there anything that you'd like
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  to touch on that that we haven't covered
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  in this conversation so far? Yeah. I think
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  more than anything else, I think facilities likely,
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  at this point, underutilized the RDR process. I
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  think there's a misconception
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  as to,
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  the the services available
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  to the arbitration process on the facility side
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  and those being limited to
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  really just ED visits.
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  There's a whole lot more opportunity than I
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  think a lot of facilities realize in in
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  engaging in IDR and understanding how the NSA
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  applies to their facilities. And even, you know,
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  worth noting, I think just last week, maybe
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  the week before, in on the HCA earnings
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  call, they identified,
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  improved outcomes in the IDR process as one
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  of the drivers of of growth. Right? So
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  there really are opportunities in the space on
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  the hospital side. And,
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  for folks who have maybe written that off
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  and and thought, hey, this is really mostly
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  for for providers,
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  facilities really ought to take a look and
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  see whether there's, an opportunity to stabilize revenue
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  through some of those IDR opportunities.
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  Excellent. Thank you so much, Patrick, for all
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  your time and insights. We also, of course,
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  wanna thank our podcast sponsor, which is HaloMD.
• 9:26
  You can tune in to more podcasts from
• 9:28
  Becker's Healthcare by visiting our podcast page at
• 9:30
  bectorshospitalreview.com.
• 9:32
  Thank you very much. Appreciate it.