June 10, 2016 | Thriving in Value-Based Care: The Impact of RCM Optimization & Incentive-Laden Programs

We are nearly halfway through 2016 and industry buzz around “Value-Based Care” remains louder than ever. New payment models are rapidly arriving with both private and public payers on board with this idea of commensurately rewarding quality outcomes.

New data shows that nearly one-third of physicians were offered a performance bonus based entirely, or in part, on “value-based” metrics last year. This is compared to 23% the year prior. Currently, 6% of total compensation is tied to quality or value-based metrics, compared to less than 5% in 2015.

So, what can be done to best prepare healthcare organizations as payment models continue to change?

According to a recent article in Modern Healthcare, successful revenue cycle management (RCM) optimization could be one of the most important attributes of a successful practice. It includes patient registration, care documentation, and reimbursement.

For physicians participating in cost-sharing agreements such as ACOs, this point is particularly relevant. Experts cite that many ACO participants often fail to generate bonuses. It’s not because they do not improve care, but because they don’t accurately attribute patients and their costs to the ACO. Or, they did not capture changes in the status of those patients that affected the cost trend.

Simply put, failure of core revenue-cycle functions can cause ACO participants to miss savings targets. They can ultimately lose out on valuable reimbursements. Further, as reimbursements shrink, it will be imperative to capture every dollar earned to ensure practice security.

Beyond revenue cycle management (RCM), there are tangible steps that practices can take for optimization. The AMA’s guideline document, “Preparing your practice for value-based care,” is a great resource. It offers five key steps to a successful transition:

  1. Identify your patient population and opportunity
  2. Design the care model
  3. Partner for success
  4. Drive appropriate utilization
  5. Quantify impact and continuously improve

Point #1 is particularly relevant when one considers Medicare’s recent emphasis on reducing readmissions and improving care for patients with multiple chronic conditions and serious health issues. For most primary-care physicians, a sizable portion of their patient population is enrolled in Medicare – there is a considerable financial opportunity if they are able to participate in opportunities to better manage this costly demographic.

As such, existing programs like Chronic Care Management reward caregivers for monthly telehealth calls to patients with multiple chronic conditions. They are a fantastic option for practices looking to boost their income while transitioning to MIPS, APMs, and other unfamiliar payment models.

On a practical level, having a clear, real-time understanding of patient status is no longer a luxury. Readmissions and other negative outcomes are starting to have a significant financial impact. Patients in your practice whose conditions are not adequately controlled are more likely to cost your practice through no-shows. They are also less likely to adhere to their medications and may call in more frequently for medication refills than patients whose conditions are well managed.

In other words, it’s becoming fiscally imperative to have a complete idea of how your patients are progressing between visits. This is something that CCM is designed to provide.

As the first contact and direct facilitator of patient treatments, primary-care physicians will essentially be the “gatekeepers” in the transition to value-based care. Savvy practices can not only survive healthcare’s identity shift but thrive during this exciting time as well. They can do this by utilizing available resources, starting RCM optimization processes, and successfully adopting high incentive programs.


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