4 Key Plays for Maximizing Incentives in Value-Based Care

By Larissa Long May 04, 2023

More providers than ever are expected to enter value-based care (VBC) over the next several years, thanks in large part to the Centers for Medicare & Medicaid Services’ (CMS) goal that nearly all Medicare beneficiaries be treated by a physician in a value-based model by 2030. 

VBC rewards providers with incentive payments for quality of care. This means compensation is linked to performance on predetermined quality and cost metrics. The healthier they keep their populations and drive down the cost of care, the greater their potential incentives.

This is exciting for the future of medicine, but it also presents some challenges.  

Most providers are familiar with the traditional fee-for-service payment structure. As they transition to VBC, they will take on a great deal of risk that they’re not accustomed to. Fear of poor return on investment may loom large as they gain their footing in this new paradigm. 

As VBC continues to grow, practices will have no choice but to face these challenges head on.

What will providers need to do to not only succeed, but thrive, in VBC? They should focus on these four key strategies to maximize incentives. 

1. Quality Improvement Via Annual Wellness Visits

Gaps in patient care can impact quality of care. The best way for practices to improve quality metrics is to close care gaps. There are many ways to do this, but leveraging the annual wellness visit (AWV) provides the greatest potential. 

AWVs Close Care Gaps

An analysis of Medicare claims from 2011-2014 showed that 62% of people who got an AWV went on to receive other preventive care services. Another study found that patients who have AWVs are more likely to get screened for osteoporosis and cancer.  

Screenings also help drive down medical costs. Research shows early cancer diagnosis can save an estimated $26 billion in healthcare spending per year. 

AWVs Provide Important Data

During an AWV, providers can gather data that helps identify high-risk patients who may benefit from extra services through care management programs. 

AWVs Provide Added Revenue  

Providers receive on average $168 for an initial AWV and $111 for repeat AWVs. AWVs can also include an advance care planning  discussion. This is a separate billable service that generates additional revenue within the AWV.  

Despite all the benefits of AWVs to patients—and the incentives they provide to practices—only about 24% of eligible Medicare beneficiaries get one.  

To proactively get patients in the door for AWVs, practices should consider seasonal scheduling. 

2. Accurate Coding

Accurate coding is a critical factor in a practice’s financial success or failure in VBC. 

Hierarchical Condition Category (HCC) coding is the primary method by which health status is captured and documented in patient records. HCC codes represent specific condition diagnoses and clearly communicate health status. 

HCC codes create an overall risk score, which CMS uses to predict future healthcare costs. This determines how much money CMS will allocate for the care of each patient based on the complexity of their case, risk of future disease, and estimated cost of care. 

For this reason, providers should use the most specific HCC codes to document patient health, especially during an AWV.  

Inaccurate coding can lead to compensation that does not align with risk. Financial implications can dramatically impact a practice’s success. Patients with complex cases need more care, which requires more money. If practices do not code this properly, they run the risk of losing revenue to care for patients who need it most. 

To ensure accurate coding, routine audits are a must. Audits identify areas of improvement in billing, coding, and documentation, and teach practices how to close coding gaps.  

Partnerships with management services organizations like Innovista Health can help. On behalf of clients, Innovista conducts various audits that offer providers and administrators valuable insights: 

  • Retrospective audits, looking back on three years’ worth of data to find opportunities for improvement 
  • Quality assurance audits to make sure documentation meets compliance standards 
  • Prospective auditing to help with patient medical chart updates 
  • Post-visit audits to verify that adjustments have been made to coding 

Practices also need systems in place to track where they succeed or miss the mark. This type of reporting gives a clear picture of year-over-year differences in revenue as it relates to coding. 

The path to coding and documentation accuracy is ongoing and involves constant education, training, and auditing. Regulations always change. Staying on top of the changes is paramount to success.

3. Comprehensive Care Management

Care management uses real-time data and predictive analytics to identify high-risk patients who need extensive care. This maximizes incentives to providers by closing care gaps and reducing healthcare spending. 

One of the biggest components of care management that drives incentives is transitional care management (TCM). This is the follow-up care provided after a patient leaves a care setting and goes home.  

Thirty-day hospital readmissions are an enormous healthcare expense. In 2018, there were 3.8 million 30-day hospital readmissions, with an average cost of $15,200 each.

Transitional care management ensures coordination and continuity of care so that the patient stays on the path to recovery without readmitting to the hospital unless absolutely necessary. One study showed 86.6% lower odds of ED readmission among those who had TCM. 

TCM maximizes incentives in a few ways. Providers can bill for transitional care visits. In addition, care managers who reach out to patients within 48 hours of discharge share what they learn with the provider, who can follow up with that patient and close care gaps.  

Practices that partner with Innovista have access to care managers who interact with patients daily to ensure transitional care and other health needs are met. In fact, by embedding a care manager within the primary hospital of one of their ACO partners, Innovista helped reduce readmissions by 25%.   

4. Technology

Without data, it’s difficult to succeed in VBC. Data are captured using innovative technologies designed to find trends so providers know where to focus their efforts.  

In fact, none of the other three pillars of VBC success can be completed effectively without the use of technology that analyzes risk, identifies gaps in quality metrics, and pinpoints patients who need more extensive care. 

To help practices realize gaps in coding and care, Innovista deploys point-of-care EMR overlay technology on behalf of clients. When they’re with a patient, providers are able to see real-time coding/care gaps and suggested actions. This allows them to not only improve outcomes for that patient, but also achieve incentives by closing care gaps and improving risk score. 

Technology can enhance patient experience and engagement, too. Online patient portals, for instance, help facilitate bidirectional communication between the provider and patient. Practices can send forms, reminders, and test results electronically, while patients can message their doctor and access educational content.  

The Bottom Line 

Since payment structures in VBC are so different than traditional models, learning how to maximize incentives is one of the most important challenges for providers to overcome. 

Innovista Health is well-equipped to help practices implement AWVs and leverage HCC coding, quality improvement, care management, and the latest technology for the best outcomes possible. 

By focusing on these strategies, providers have the best chance of succeeding and thriving in value-based care.