With the advent of MACRA, CMS has begun to shift healthcare reimbursement from fee-for-service to one based on achievement of value-based metrics. The goals of Value-based care are to improve care quality and lower costs. Independent providers must overhaul their financial and clinical processes to realize success under the model and must now fulfill quality reporting tasks, monitor patient outcomes inside and outside of the practice, track financial outcomes, and more.
Commercial payers are following suit with incentive programs and cost-sharing opportunities. Currently, most commercial insurance programs do not have negative incentive programs. This means that there are no penalties that are associated with the quality and value programs that the commercial insurance programs have available. However, in most states there are great incentive programs that you can participate in through your insurance company that provide no penalties.
Strategies for independent practitioners to not only survive but flourish in a value-based environment include:
Value-Based contracts have clinical outcome metrics, promoting interoperability metrics and patient experience metrics. These metrics are based on governmental regulations and evidence-based guidelines developed by integrating the expertise of a multidisciplinary group of clinicians with the perspectives of consumers and the best available research evidence.
2. Transforming the Way Care is Delivered in an Office Environment
In a value-based model, primary care providers are expected to develop ongoing healing relationships, whole-person orientation, incorporating a family and community context, and comprehensive and coordinated care. Through transformation, practices seek to improve the quality, effectiveness, and efficiency of the care they deliver while responding to each patient’s unique needs and preferences.
3. Implementing Care Management and Coordination
In order to achieve the expected outcomes and performance required by value-based contracts, primary care providers are expected to provide care management, and care coordination across the medical neighborhood. Quality improvement lays the foundation for practices to meet expected outcomes. With a focus on health outcomes, practices will need an infrastructure that supports population health management and risk-stratified care management. Utilizing processes and coding such as Transitional Care Management (TCM) and Chronic Care Management (CCM) will assist in the implementation of new processes and may provide additional funding to support those changes.
4. Develop Care Team Delivery System
Team-based care is defined by the National Academy of Medicine (formerly known as the Institute of Medicine) as "...the provision of health services to individuals, families, and/or their communities by at least two health providers who work collaboratively with patients and their caregivers—to the extent preferred by each patient - to accomplish shared goals within and across settings to achieve coordinated, high-quality care”.
5. Utilizing an Electronic Health Record with Analytical Capabilities
Having an EHR that collects and presents that information for the practitioner is just half the battle; the information will need to be better organized in a way that is useful for decision support. Practitioners and their staff use an electronic health record to efficiently manage their workflow. EHR acts as a highly interactive Health IT platform where the entire patient-provider-clinician’s interactions are streamlined to bring about successful patient care outcomes.
Transforming an independent practice to ensure success in the value-based programs requires a significant change in the culture and organization of care, in the nature of interactions among colleagues and with patients, in education and training, and in the ways in which primary care personnel and patients understand their roles and responsibilities.
Lynn Guerrant is the Director of Quality Compliance at R1.