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 will be treated by a physician in a value-based model by 2030.
VBC rewards providers with incentive payments for quality of care, meaning 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 into VBC, they’ll assume a great deal of risk that they’re not used to taking on. 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. So, the question becomes: What do providers need to do to not only succeed, but thrive, in VBC?
There are several ways to foster financial success in VBC—but providers should prioritize four key plays to truly maximize incentives.
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 by leveraging the annual wellness visit (AWV), providers stand to maximize incentives in more ways than one.
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. A more recent study found that patients who have AWVs are more likely to close care gaps by undergoing preventive screenings for osteoporosis and various cancers.
Screenings also help drive down medical costs. Research shows early cancer diagnosis can save an estimated $26 billion in healthcare spending per year.
The AWV is a standardized way for practices to collect data that can be used to assess risk and identify patients who need additional care through care management programs.
Providers receive on average $168 for an initial AWV and $111 for repeat AWVs. AWVs can also include a discussion of advance care planning. This is a separate billable service, offering the ability to generate 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 using techniques such as seasonal scheduling.
Accurate coding is a critical factor in a practice’s financial success or failure in VBC.
HCC (Hierarchical Condition Category) coding is the primary method by which health status is captured and documented in patient records. HCC codes represent very 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’s not aligned with risk. Financial implications can be huge and dramatically impact a practice’s success. Patients with complex cases need more care, which requires more money. If this is not coded properly, practices run the risk of losing revenue to care for patients who need it most.
To ensure accurate coding, routine, in-depth audits are a must. Audits identify areas of improvement in billing, coding, and documentation, and help educate practices on ways to close coding gaps.
Partnerships with value-based/managed service organizations like Innovista Health can help. On behalf of clients, Innovista conducts various audits that offer providers and administrators valuable insights:
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, and staying on top of the changes is paramount to success.
Care management uses real-time data and predictive analytics to identify high-risk patients who could benefit from more extensive care. This maximizes incentives to providers by closing care gaps and reducing healthcare spending—especially emergency department (ED) utilization.
One of the biggest components of care management that drives incentives is transitional care management (TCM)—care provided when 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. TCM employs a set of actions to ensure 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 an 86.6% decreased 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 any gaps in care.
When partnering with an organization like Innovista, practices have full access to care managers who interact with dozens of patients daily to ensure their TCM and other health needs are met.
One strategy Innovista has implemented is embedding a care manager within the primary hospital of one of their ACO partners, resulting in a 25% reduction in readmissions for those engaged members. This success is attributed to identifying patients at high risk for readmission and ensuring they are set up with services and resources to support a successful transition.
Much like care managers, community health workers (CHWs) work to close care gaps by supporting patients’ physical, mental, and social needs through community resources and services.
CHWs educate patients about choosing appropriate medical care settings, thus saving them time and money by reducing the overutilization of the ED. CHW outreach benefits providers and payers, too. Their services have been shown to increase ROI and decrease costs for practices.
Technology serves the dual purpose of helping patients take a proactive approach to their healthcare while enabling providers to maximize incentives.
Without data, it’s difficult to succeed in VBC. That all-important data is captured using innovative technologies designed to find trends so that 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 attention through care management.
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 through coding gap closure.
Technology can enhance patient experience, 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 email their doctor with questions or requests and access educational content.
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 accurate HCC coding, quality improvement, care management, and the latest technology for the best outcomes possible in a VBC landscape.
But by focusing on the plays discussed here, providers have the best chance of succeeding—and thriving—in VBC.