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Overcoming the Value-Based Reimbursement Challenge

It’s no secret that the transition from fee-for-service reimbursements to value-based reimbursements (VBR) has forever altered the way providers and plans operate their businesses. The increased emphasis on quality care, rather than quantity care, has dramatic implications on member health, but comes with an equally substantial impact on the participants in the delivery of health care services. The necessity for value-based metrics, improved documentation accuracy and elevated reporting requirements have proven to be burdensome on plans and providers alike.

The Challenges

In 2015, the Medicare Access and CHIP Reauthorization Act (MACRA) was passed. MACRA instituted significant changes to the reimbursement model for plans and ushered in Quality Payment Programs (QPP) designed to change the expectations of patient care and lower health care costs. Along with those programs, was an aggressive timeline to have the industry align with the new rules of engagement in a few short years.

To succeed in the MACRA QPP, participating providers needed to demonstrate that they could control costs, improve quality, use electronic health records (EHRs) and other health care IT in patient care, and improve and streamline clinical processes. Such reporting must occur while providers maintained their other reporting responsibilities. For health plans, which need to acquire and report their own risk-adjustment data, the increased reporting burden for providers created an immediate need to cut across risk-adjustment and quality processes and foster greater provider engagement.

Because of the shift from simply tracking provider throughput, to now adding context to each provider-patient interaction, the data needs grew exponentially. It was no longer as simple as, “I ordered these tests for this patient”, but “Based on these criteria, I believe the patient is suffering from this condition, and requires these tests to confirm and treat.” Additional steps and responsibilities were added after the initial diagnoses and treatment to reflect outcomes and results. The emphasis on documentation accuracy by the providers, and data aggregation and translation on the health plans became huge… overnight.

With more burden placed on the providers, physician morale and burnout reached critical levels. A 2016 survey of more than 17,000 physicians across the United States found that many physicians are unhappy, burnt out, and frustrated that they don’t have the time for the most important part of their jobs—their patients. Many are considering quitting clinical work and recommending that family members not join the profession. These physicians cite regulatory and paperwork burdens and loss of clinical autonomy as the main sources of their dissatisfaction. Many specifically cite the ICD-10 system as a barrier to practice improvement. Only 14 percent of physicians responding to the survey said they have the time they need to deliver the highest standards of care, and just over 89 percent said that EHRs have offered little or no improvement to the quality of their patient interactions or have detracted from that quality.

A Path Forward

Despite the uphill climb in transition to value-based care, there are solutions available that have shown to significantly improve the ability of both providers and plans to rapidly adjust to the requirements of MACRA, while strengthening their business on a larger scale. The tent-pole of this change is a focus on increasing engagement and coordination between plan and provider. Under a value-based model, health plans are more reliant on their providers, and providers are placed under additional pressure to align with plan needs. It is no longer possible for these two groups to work in isolation from one another.

A Role for Health Plans

Under this new paradigm, the onus falls on the health plan to ensure that their providers have the understanding of what is required of them, and the tools necessary to support the plan efforts. If health plans can find ways to streamline collection and analysis of data – through the development or implementation of new technology designed to address the data collection requirements – and relieve their reporting burdens, while also relieving some of the burdens for providers, mutually beneficial health care analytics partnerships can be achieved.

One effective tactic for health plans is to provide greater assistance in the area of health record accuracy. For Medicare Advantage plans, CMS requires annual documentation of chronic conditions for members/patients. Health plans can assist providers by reviewing member charts retrospectively to identify both historical chronic conditions and ensuring all undocumented or poorly documented conditions are correctly tracked for risk and quality purposes. These same members/patients may have HEDIS measures that also need to be tracked. Similar measures are being tracked by providers for reporting on QPP categories.

This review effort often involves a massive volume of information, requiring a team that is proficient in a thorough retrospective process, with the ultimate goal of establishing a prospective plan to close care gaps, address HEDIS measures, and provide QPP documentation for providers. Because all of this documentation occurs at the point of care, success and provider trust are predicated on a great deal of effort behind the scenes by the health plan, or its surrogate, for the benefit of the provider. The work must not task the provider staff or interfere with the clinical flow, but the initial review effort and team should involve anyone in the provider organization with responsibility for entering information into the EHR or extracting information from it.

The success of this type of coordination requires a deep understanding of provider habits and friction points. For these reasons, it is important that the outside work be supervised by a provider so that the important interaction is conducted at a peer-to-peer level; provider to provider. This interaction is best accomplished when the liaison between the health plan and provider office works to establish trust and can clearly articulate the value brought to the individual provider and his or her patients.

These reviews should sensitize the medical record to become a more easily utilized tool for the clinician at the point of care. The tool within the medical record must allow a quick (60- to 90-second) review by the provider to encourage actions at their discretion. These actions should then be captured compliantly within the medical record.

When providers are then engaged prospectively for member outreach, so that these previously uncaptured conditions are addressed at the point of care, some positive things occur:

  • Patient care, outcomes, and satisfaction improve.
  • Risk-adjustment care gaps are closed for accurate payment on the health plan side.
  • HEDIS/quality measures are coordinated so there is less member or provider abrasion.
  • Providers spend less time interacting with the EHR and more time in face-to-face interaction with patients.
  • Providers more easily and accurately collect information needed for QPP reporting categories of advancing care information, improvement activities, and quality.

Another benefit for providers is that this team effort between them and the health plan gives them concrete, reportable examples of active measures they have taken to improve meaningful use of EHR technology, health care quality, and practice efficiencies.

Again, the potential for positive results is greatly increased when trust is established with providers as a result of successful peer-to-peer interactions focused on clinical outcomes—not code or measure capture—and when the work does not interfere with patient care. By supporting the provider retrospectively at the point of care and prospectively for risk-adjustment, quality, and MACRA documentation requirements, a collaborative process allows providers to devote more time to what they do best and value most—caring for patients. The result of this process is more accurate payment.

Accelerated Transformation

Through improved technology, increased understanding and expertise, and enhanced provider engagement, health plans can accelerate their evolution into a highly-functional, value-based operation. While some plans have opted to attempt these changes internally, with slow and painful results, many plans have chosen to lean on companies that specialize in this to help them achieve growth more rapidly.

Whatever path you choose, there is no arguing the significant need in our industry to improve the coordination between plans and providers. Not only can it greatly improve the effectiveness of both parties, but – more importantly – leads to better care and lower costs for your members.

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