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From the Consultant’s Corner 3/2/17

March 2, 2017 From the Consultant's Corner 1 Comment

Value-Based Reimbursement: Five Success Factors for Medical Groups

Despite uncertainty about the future of the ACA, value-based reimbursement will remain an unwavering reality in healthcare. While leaders may disagree over specific legislation, all approve the overall goal of value-based reimbursement, which is to encourage both cost reduction and improved patient outcomes.

That means medical groups should continue to explore value-based opportunities through commercial payers and CMS. For example, MACRA, which takes effect this year, consolidates previous programs including Meaningful Use, PQRS, and Value Based Modifier. Approved by a bi-partisan Congressional vote, MACRA is likely to stand as enacted and impact a significant portion of practice Medicare payments starting in 2019. Yet MACRA isn’t the only initiative designed to enhance revenue and patient care. Medical groups can also take advantage of programs such as Chronic Care Management, Transitional Care Management, Patient Centered Medical Home, and Bridges to Excellence.

No matter which value-based path a practice chooses, there are five factors that will be integral to success:

1. Patient engagement. Reports show that patients who are engaged in their care have better outcomes,[i] and most patients desire deeper involvement. So what’s the obstacle? Transparency. Medical groups will need to be more transparent about their services and costs to engage their patients.

2. Investments. Achieving transparency requires access to information. Practices need to invest not just in EHR and PM systems, but also in frequent training to expand their use. By now, most providers have an EHR; 78 percent of all office-based physicians and 96 percent of all non-federal hospitals had a certified EHR as of 2015.[ii] The key going forward is to optimize those systems and workflows to accomplish value-based objectives.

3. Data and analytics. Data truly is king. Creating appropriate data in EHR and PM systems — and then analyzing it through business intelligence software — enables practices to best evaluate the needs of their patients. Ensuring accurate ICD-10 coding, for instance, helps practices paint a more precise patient picture.

4. Population health. With data and analytics, practices can better identify gaps in care and the target those patient populations most in need of intervention. For example: The PQRS and MU quality measures that are now part of MACRA are also being used by many commercial payers. Obtaining this quality data at the point of care — rather than from retrospective reports — allows practices to effectively use resources to proactively engage patients and improve their care.

5. Practice performance/EHR workflow. Efficiency will continue to gain importance as value-based reimbursement models reward reduced costs and increased patient satisfaction. To fuel the kind of efficiency that lowers cost and makes patients happier, make sure providers are maximizing the EHR’s capabilities at the point of care.

Together Toward Value

While data, technology, and patient engagement will lay the foundation for value-based reimbursement, be careful not to overlook the importance of governance as well. More than ever before, practices must bring together their CMOs, CMIOs, CFOs, IT directors, and other organizational leadership to develop a unified value-based care strategy. Consider establishing a governing council to evaluate value-based opportunities, inform and train staff, and implement plans. Solidarity, communication, and attention to the five factors listed above will go a long way toward achieving a smooth transition to value-based reimbursement.

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By Randall Shulkin, executive consultant, Culbert Healthcare Solutions


[i] Patient Engagement Report: Improved Engagement Leads to Better Outcomes, but Better Tools Are Needed; Insights Report; May 12, 2016; Kevin Volpp, MD, PhD & Namita S. Mohta, MD

[ii] Health IT Dashboard; The Office of the National Coordinator for Health Information Technology; January, 12, 2017


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