A decade of value-based care: Tammy Schaeffer, JD, RN

Tammy Schaeffer: ©Plante Moran

A decade ago, the federal government launched its large-scale Medicare Access and CHIP Reauthorization Act (MACRA) in an attempt to move more physicians into value-based care to rein in exploding costs and improve care.

In July, Medical Economics will release the second edition of Medical Economics Insider featuring an in-depth look at how successful MACRA has been and what the future of value-based care looks like, both from the government and from private payers. As part of that extended coverage, we are featuring an advanced look at some of the experts we talked to, offering additional insights into value-based care and what doctors need to know moving forward.

Medical Economics spoke with Tammy Schaeffer, JD, RN, principal with the consulting firm Plante Moran, about why value-based care hasn’t been adopted more quickly.

(Note: The transcript has been edited for brevity and clarity.)

Medical Economics: So why is fee-for-service so entrenched in US health care, despite years of value-based care initiatives like MACRA and also other initiatives on the private payer side?

Tammy Schaeffer: One, we have spent 40-50 years talking to people about incenting volumes and doing more. Organizations have put a lot of emphasis and a lot of infrastructure behind succeeding in a fee-for-service environment. The simple reality is that's not undone overnight. As we've started to identify the studies and see the measures that really show that more isn't always better, and outcomes can be generated in a more effective way through a value based contingent, it's a complete unwinding in some ways of the way that we've done things for 100 years.

Medical Economics: Why would a physician that doesn’t see a problem with the status quo want to move to value-based care?

Schaeffer: One, I think the biggest difficulty with moving from fee-for-service to a value-based contract is that you can't go purely value-based. There's no such thing as having a fully value-based platform for organizations and especially physician practices. The smaller physician practices don't have the luxury of saying, we're going all in on value. They have to have one foot in the fee-for-service canoe and one foot in the value-based canoe. And that really creates extraordinarily difficult situations for them, because working toward one can actually shoot them in the foot on the other. I've never met a physician who didn't go into medicine because they wanted to help people. And so this, the value-based care platform, is precisely what allows physicians to connect the passion that they had to help people with appropriate reimbursement for the work that they're doing. We've talked for 100 years about patients who are really difficult or non-compliant or have social determinants of health, and how that makes the work so much more laborious and difficult for the physicians to achieve the outcomes. Value-based care is the first system and the best system that really rewards all of the things that they've been doing all along to keep the patients healthy, but appropriately aligns reimbursement with the great outcomes that they're delivering as a result of all of that work.

Medical Economics: From the physician perspective, what's the biggest obstacle to transitioning away from fee-for-service?

Schaeffer: I think it's financial in terms of folks have payer agreements that are incented on fee-for-service and payer agreements that are value based. The two of those things are not always aligned. As you're looking toward value-based agreements, really look at some of the upside to downside arrangements, to give you that time to make the transition. Physicians, especially smaller practices, may not have the luxury of flipping a switch and going from one to the other. They're going to have to learn how to function in both, and those upside to downside arrangements are really pivotal in helping them learn to function at-risk and do well, and build it into their fee-for-service based systems so that they can achieve in both. Secondly, it is a complete paradigm shift in terms of value-based care uses the hierarchical condition coding system, which many physicians don't know and really haven't had a lot of exposure to. It's not something that they're teaching in medical school. So as they come out and they're really learning that, it really turns care and documentation on its head. The great thing is it aligns with what the physicians want to do, which is take care of the patient. But it is a change, and I think that's something that has to be acknowledged, and it also has to be something that is an intentional investment attached to it. Practices looking to make the transition really need to assess where they are and what their systems are, so that they know where to make the right investments of infrastructure to help them succeed in value-based care.

Medical Economics: Many doctors feel overwhelmed or intimidated by the reporting and administrative side of value-based models. Are these concerns still valid, and how can they be addressed?

Schaeffer: The concerns are absolutely valid. When you're looking at where you need to invest for infrastructure, analytics and the administrative portion of that is absolutely something that must be considered. So those concerns are absolutely valid. Most of the insurance company data that is provided to a lot of the practices is oftentimes six months or older. If you don't have the right infrastructure in place, you can have a bad day and not know about it for six months. And you want to be able to make changes to your care processes and to things that aren't working much more timely than simply reacting to some of that provider data. So, as you're looking at infrastructure, working to ensure that you have the right analytics in place and that you have the right capture of the things that you need to put through whatever electronic health record that you're using, so that you can make those decisions timely, is imperative. One of the things that I personally feel very strongly about is if the government and CMS really wants to move toward value, they're going to have to provide some semblance of reimbursement for the infrastructure that is required to really execute this in an effective fashion. The organizations that are doing this well are those that are extraordinarily data savvy, and that doesn't always mean that it's the largest organizations. There are small physician practices that are doing this very well. What they've done is they've invested in their technology and in understanding their record and understanding how they're doing in a much more timely fashion, and they've created strong buy-in among their providers as to the value of value-based care. Once you marry those two things, your potential is essentially limitless.

Medical Economics: What steps can a practice take to begin preparing for this shift, if they don't have anything as far as infrastructure or support today?

Schaeffer: The first thing I would say is a very easy step that can benefit both fee-for-service as well as value-based care is looking at your accessibility. Accessibility is the number one leading indicator to success in value-based care. It's can you see the patients in a timely fashion, and can you see the right patients at the right cadence to manage their illness and their comorbidities in a way that doesn't result in acute utilization or complications. What is the risk of the patients that you're treating? Do you have mostly older adults? Do you have a family practice that has a lot of younger folks?

The other thing is many physicians think they have a fantastic documentation practice or a fantastic record, and they're very shocked when they get their average RAF (risk-adjustment factor) score, because they see the patients so much sicker than they're appearing on paper.

One of the first things that you can do to make sure that you're reimbursed properly is make sure that your documentation system matches what you're looking at when you're seeing patients, and that you've got good, strong capture of the things that you're doing for the patients that will help you on a fee-for-service basis as well.,

The third thing is talking to providers about what value-based care is, the importance of it, and what it really means. The word value-based care has become, in many ways, kind of a buzzword. It means a lot of different things to a lot of different people. So understanding what it means in the terms of your value-based arrangements, what value-based arrangements you might be looking at with any payers, and the changes that need to be made, and really engaging your physicians and your providers very early on in that process is very important. If you don't have their buy-in you, you won't be very successful. And if you're playing catch-up after you already signed one of these agreements, it's much harder than engaging them at the beginning to help you build the systems that will manage that care in an effective and the cost-effective way that will help you succeed in in value-based arrangements.

Medical Economics: What role do payers and health systems play in helping physicians make this transition to value-based care, and are they doing enough?

Schaeffer: Hospitals and health systems have a really a vested interest in helping the private practice physicians and ambulatory practices succeed in this, because when you're looking at the populations and the patients that they're caring for, they have every incentive in helping to do that well so that when patients do leave their doors, they're able to comfortably and respectfully integrate back into their home without bouncing back to the hospital as a readmission or as a complication or something like that.

Payers, I think, are becoming much more helpful in a partnership standpoint with providers. These are folks who are taking a large swath of patients, and particularly managed Medicare from the government and helping manage care and manage utilization. They really have every incentive to work with you. I think part of the responsibility in that partnership is actually on the physician practices. Payers have tremendous amounts of resources dedicated to the care of their patients. They oftentimes have complex case management resources. They have resources to impact social determinants of health. They have behavioral health resources, things that smaller practices don't necessarily have the luxury of investing in. Many times, payers have programs that are established for those patients, and it's as simple as working to connect with them, understanding what is out there and available for patients and how they might work together to make sure that they're leveraging that in the right way for the right patient.

Medical Economics: What are some misconceptions that physicians have about value-based care?

Schaeffer: I think really one is that it can't be appropriately reimbursed. And the reality is, it's exactly the opposite in that context. For one of the first times, it's actually appropriate reimbursement for all of the work that they're doing to take care of the patient, and especially those high-risk patients. The other misconception is that they have to do duplicate work, and that is also really not true in terms of the HCCs are embedded above the ICD 10 diagnoses. So you're really kind of doing the same work to the patient.

Medical Economics: Is there anything else about value-based care that you think physicians should know?

Schaeffer: Value-based care is not just the physician’s job. One of the biggest mistakes that I see in practices nationally is that the entire burden of coding and risk adjustment factor and value-based care as a whole is put onto the shoulders of the physician or the provider, and nothing could be less successful than that. It is imperative that every person in the office understands value-based care. Just like it's been 100 years that we've told physicians, you have 10 minutes to see a patient and as many as you can get through in a day, and you need to do this many visits. The reality is, we've done exactly the same to our support staff, as well. So your MA, your care managers, they're all in a fee-for-service mentality, as well. Help them understand how the value-based care system works, how reimbursement works in value-based care, and how all of these things align to help them provide better and safer care to the patients. If you can help them understand that, they will help you as a physician succeed.

Also, look at who you've got doing what job. Just like it can't be on the physician’s shoulders to do all the documentation, all of the care, the responsibility for identification of risk, also can't be just the physician’s job. Anyone who's been in health care for more than a few minutes knows that there's a situation where you go talk to a patient, the patient tells you everything, and then somebody else comes out and says, did they tell you about this? But they didn't mention that, or they tell one person one thing, and one person another thing. And so it's really the conglomerate of the office that's going to help you identify what's truly going on with the patient. And patients develop different relationships with different folks. It's important that they develop a relationship with your MA, your nurses, your care managers, any of those, because all of those people are pivotal to really truly understanding what's wrong with the patient, and you being able to capture those diagnoses and the ability to manage them as you're seeing the patient.

The other thing is that for physicians, a dedicated and purposeful investment in learning the hierarchical condition coding system and how the reimbursement structure works is very important. It is a very intentional way of doing things. It's intended to recognize the risk and the severity that patients bring forward and create a tool for you to help manage those conditions in a way that prevents progression of illness and prevents complication of illness. And one of the first keys to understanding that is really understanding what and how the hierarchical condition is. It can also be a very valuable tool for you as a provider to understand who your high-risk patients are and who you should be seeing more frequently, and how you triage needs and those types of things. So really dedicate yourself to understanding how it works, and then use your provider insight to understand how you can integrate that into the systems that are in place in your office to help you drive care more efficiently and more effectively among the folks that you're treating. That is imperative and that all starts with education.

I want practices to know that it will be just as pivotally important for you to have an effective data analyst as it will be for you to have an effective MA. The data is what will help you make changes to your practice that will help you drive care and clinical outcomes and reimbursement in the way that you're intending to do. And so for many small practices, what I hear when I'm talking with some of the physicians is they say, well, I'll do that on the weekend, or I do that in the evening. And the reality is, we want those clinical folks focused on clinical practice. You want to be supported by a data analyst, and you have to really get in the mindset that the analytics are an essential arm of your practice, and that an intentional investment in them is what will help you succeed in everything that you're trying to do, versus it's just one other hat that I, as the provider, wear.