Regarding “Two-sided risk may pose too hefty a price for some oncology practices,” the CMS’ plans are simply the recycling of the HMO version of managed care, but one where the individual provider practices bear risk (based on a few thousand patients), rather than the insurance company (based on multiple millions of patients).
However attractive such a simple “solution” appears, it suffers a fatal flaw. An insurance company bearing risk has a much greater likelihood of having a panel of patients that closely resembles the models the CMS uses to set “expected” costs plus a small incentive. Only the volume of the patient population allows an insurer to gamble on winning more than losing with some expectation of not going broke. Even the best cherry-picking physician knows they don’t face the same odds, but are more significantly at risk.
Notoriously, the government (and much of the public) considers it somehow unethical or a waste of money to actually allow providers to profit proportionally to the amount of money novel (but otherwise unreimbursed in fee-for-service) strategies can save government programs. Thus, for the current “risk-sharing,” the government does not offer (indeed, cannot offer) enough upside/potential reward to entice the providers to risk a big (practice-ending) loss if one or two patients need extraordinary care.
Dr. Kiran C. Patel College of Allopathic Medicine
Nova Southeastern University