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Experts: conveners can enable specialists to enter population‑based risk, but upfront cash flow and ASO contracting obstruct scaling
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Summary
Speakers at an HHS PTAC session described how conveners aggregate actuarial capacity, capital and data to allow small specialty and independent practices to participate in population‑based total cost of care models, and they flagged prospective payments and the ASO (administrative services only) market as persistent barriers.
At an ASPE PTAC listening session, Dr. David Johnson, clinical operating partner at Rubicon Founders and practicing urologic oncologist at the University of North Carolina, said conveners can be essential for enabling specialists and smaller practices to join population‑based total cost of care contracts.
“Conveners engage multiple stakeholders,” Johnson said, and they commonly “aggregate risk across multiple practices, geographies, lines of business and payers” so that small to mid‑sized specialty practices can achieve actuarial stability and participate in risk contracts.
Why it matters: Specialists and independent groups typically lack actuarial expertise, cash reserves and population‑health technology needed to assume downside risk. Conveners can provide capital, real‑time claims and clinical aggregation, staff for care management and analytics to identify cost variation and project expenditures.
Panelists and committee members discussed two recurring obstacles: - Upfront cash flow: Johnson and other presenters said shared‑savings or outcome payments often arrive only after a full performance year plus months of reconciliation, creating a long lag. Conveners may need capital backers to advance prospective payments so providers remain engaged. Johnson called for payer willingness to “front the flow of funds” or a reasonable ramp to two‑sided risk to sustain providers during the period before shared savings materialize. - ASO contracting complexity: Multiple panelists, including PTAC members, described the administrative‑services‑only market as a structural barrier because commercial payers serving self‑insured employers do not want to renegotiate dozens of employer contracts for convener arrangements. Several panelists said the practical response has been to negotiate directly with large employers or to “tuck” convener services into broader value‑based arrangements rather than rely on a one‑size‑fits‑all ASO pathway.
Additional points from the discussion: - Conveners pay for non‑revenue staff and technology (population health platforms, patient‑reported outcome tools, dashboards) that independent practices cannot easily fund. - Conveners can shield providers from downside risk and maintain statutory capitalization required for two‑sided contracts. - Payment models that include prospective, per‑member or interim payments during the performance year help maintain provider engagement while shared‑savings reconciliation is pending.
Ending: Panelists recommended that payers, employers and conveners explore practical payment flows—prospective interims or subcapitation for primary care—so that specialty practices and independent providers can participate without undue cash‑flow exposure.
