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.

Case in point: 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, 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 we move further into a time of change when it comes to payment models? According to a recent article in Modern Healthcare, successful revenue cycle optimization – including patient registration, care documentation and reimbursement – could be one of the most important attributes of a successful practice.

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 not because they do not improve care, but because they don’t accurately attribute patients and their costs to the ACO, or else 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 and, ultimately, lose out on valuable reimbursements. Further, as reimbursements shrink, it will be absolutely imperative to capture every dollar earned to ensure practice security.

Beyond revenue cycle management (RCM), there are tangible steps that practices can take to best prepare. The AMA’s guideline document, “Preparing your practice for value-based care,” is a great resource, and 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, which rewards caregivers for monthly telehealth calls to patients with multiple chronic conditions, are a fantastic option for practices looking to boost their income as we transition 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, with readmissions and other negative outcomes 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, are 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 – something that CCM is designed to provide.

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