Although value-based payment models offer several advantages over fee-for-service models, practices are sometimes reluctant to try them out of fear of requiring additional documentation and workflow changes.
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Healthcare in the U.S. has traditionally been fee-for-service, with doctors paying and getting reimbursed for each service they provide. But in recent years, more and more doctors and payers have been experimenting with value-based payment models, in which doctors are paid based on how well they care for their patient population while keeping costs in check. The 2020 Healthcare Payments Learning and Action Survey Network found that just over 60 percent of healthcare payments include some form of quality and value component, up from 11 percent in 2012.
Although value-based payment models offer several advantages over fee-for-service models, practices are sometimes reluctant to try them out of fear of requiring additional documentation and workflow changes.According to the proposal during the meeting medical economics® 2022 Fall Physician Boot Camp, a strategic approach incorporating the right technology can help ease the transition to value-based care.
How value-based insurance contracts can increase revenue and give physicians more time to provide better care to patients, and how to get started.
How the documentation and reporting requirements differ in a value-based insurance contract.
How your electronic health record (EHR) can and should be designed to make value-based success easy.
meet with group members
Sara Pastor, MD, MHA, FAAFP
Director, Primary Care Development
Vice President of Practice Innovation
Fee-for-service, in which doctors are paid for personal services, has long been the foundation of the U.S. health care system. But over the past decade or so, alternative payment models in which providers are reimbursed based on patient health outcomes have begun to emerge and become more popular.
That’s partly because these alternative payment models have multiple advantages over fee-for-service drugs, said Sara Pastor, MD, MHA, FAAFP, director of primary care development at EHR provider Elation Health. Pastor defines a value-based delivery model as “providers who are rewarded for helping patients improve their health, reduce the impact and incidence of chronic diseases, and lead healthier lives in an evidence-based manner.”
One of the advantages offered by the value-based model is the monthly capitation offered by many payers to enable physicians to implement population-based care. “Because you get predictable monthly cash flow, you have more flexibility in delivering designs,” Pastor explained. “That means you don’t have to think, will I get paid more for handling a patient’s problems in person than for a telehealth visit or a phone call?”
Guaranteed regular income also improves the financial resilience of the practice, Pastor added, noting that at the height of the COVID-19 pandemic, value-based contracts performed better than practices that relied solely on service fees.
Pastor explained that current payment models fall into four broad categories based on reliance on fees for services and focus on patient outcomes. The first is the direct cost of the service, independent of quality and value. Second is a service fee with limited financial incentives based on patient outcomes.
The third is alternative payment models built on fee-for-service structures, including those that offer shared savings or shared risk. Finally, there are population-based models, in which doctors are paid partly or fully on a per-capita basis.
“On a per-capita basis, primary care providers own the entire patient care process, including outcomes and total cost of care,” Pastor explained. “The better the results, the lower the cost of care, and the more money doctors can make. The goal is to eliminate unnecessary and sometimes harmful care, reducing costs while improving the health of the population under provider care.”
Pastor cites figures that show direct payments for services fell from 62 percent in 2015 to 39 percent in 2020, while population-based payments, too small to measure in 2015, will account for 7 percent in 2020. “While population-based payments are increasing, we do see (service fees) remain the main driver of compensation for healthcare providers,” she said.
Manisha Goud, vice president of practice innovation at Elation Health, explained that one of the keys to success using a value-based model is a patient’s risk score, which is used by Medicare, the largest payer in the U.S., to relatively measure the cost of meeting a patient’s care needs. Medicare assigns each beneficiary a risk score, also known as a risk adjustment factor, based on the patient’s health status and demographic factors. The higher a patient’s risk score, the more a provider will pay to manage their total cost of care.
In addition to determining reimbursement costs for each patient, risk scores can be used to identify high-risk patients who need care most, Goud added. EHRs can help with this task by creating an algorithm that enables physicians to risk stratify each patient’s population based on their overall health and demographic characteristics. “You can then stratify patients based on risk and allocate resources directly to those who need them most,” she said.
A good way to start the transition to value-based care is to participate in Medicare’s Transitional Care and Chronic Care Management programs, both of which have specific billing codes and time-based fees related to care delivery and billing, suggested Goud. Require. EHRs can help build templates to track time requirements and match the correct code to the type of service being offered, she added.
In addition, Goode recommends joining an Accountable Care Organization (ACO) that focuses on primary care. “We’ve found that ACOs have been key to reducing the administrative burden of primary care practice (value-based planning) and can support your success in care delivery as you navigate a changing payment and delivery environment,” she said.
Points and Solutions
When choosing an ACO to join, look for an ACO whose motivation and culture is focused on the needs of primary care, not the needs of the hospital system.
Use risk-adjusted scores as a tool to stratify patients according to the complexity of their needs. A high score may indicate the need for additional resources.
The risk-adjusted score is updated at the beginning of each year based on demographic and diagnostic data for claims from the previous year. This means that patients’ health status must be assessed and coded annually to maintain their risk-adjusted scores.
Combining per-patient monthly payments on a value-based contract with performance bonuses and shared savings plans can lead to higher earnings and smaller patient groups.
Use your EHR to connect to other care locations, such as specialists and labs, so you can understand what kind of care your patients are getting and where they’re getting it.