From challenge to change: Best practices for value-based care in physician practices

Tammy Schaeffer: ©Plante Moran

Value based care remains a top priority in health care, and physician practices of all types are feeling the pressure from payers to take on more risk. Despite this national trend, many physician practices have been slow to embrace these models, in part due to concerns about the ability to win in risk-based arrangements, while also performing well in fee-for-service agreements. Adopting a value-based approach to clinical, financial and administrative operations can help physician practices thrive in both worlds. This can help streamline the transition to value-based care, while ensuring better patient outcomes and greater financial stability for providers and practices.

How can a physician practice enable more value-based operations? Here are a few best practices to consider.

Start small but dream big

For physician practices new to value-based care, pursuing agreements that offer an upside-to-downside-risk approach provides an opportunity to enter the value-based environment more comfortably. During the upside portion of these agreements, practices should monitor what their performance would be if the risk were downside and focus on improvements in areas that would impact full-risk performance. Collecting and sharing data that shows full-risk performance allows the practice to use the upside-only period to fine-tune its systems and processes for optimized performance when the contract transitions to full risk.

Take a hard look at current performance

Even if a physician practice does not yet have value-based contracts, it is helpful to review performance with fee-for-service quality measures. Most gain share agreements are contingent upon practice performance at a 4- or 5-star level in HEDIS (Healthcare Effectiveness Data and Information Set) measures. This means that to capture the savings you’ve created through strong patient management, you must also score at a high level in HEDIS. If a practice struggles to perform in these measures, it often indicates practice operations issues that may create poor performance in a value-based model. Taking the time to see all patients annually, and to see higher-risk patients at a more frequent cadence, combined with practice operations improvements that drive strong performance in the administrative components of HEDIS, can help set you up for success in risk-based models.

Consider an independent assessment

Although a physician practice may receive payer data about certain patients, it shouldn’t assume that this snapshot will give them the full picture of population risk and practice performance. An independent assessment is an inexpensive option to help you identify not just the baseline on how the practice is performing, but also how the operations are fine-tuned to win in both value based and fee-for-service agreements. An assessment can also help you more accurately quantify where patient population risks are, what the disease load is, and where your practice should invest to effectively manage risk.

Value-based care is a team sport

In order to win in value-based care, every person in your office needs to be working at the top of their license to identify, document, and manage patient risk. Not only does this reduce the burden on the individual provider, it establishes a deeper, practice-wide rapport with patients, which can further help identify and manage chronic and high-acuity conditions. With this approach, a patient access team could confirm insurance, but also verify patient demographics and screen for social determinants of health—two key elements involved in calculating and managing risk. Similarly, a medical assistant could complete assessments that cue the physician where there might be chronic or high-risk conditions to manage. Using these roles to the fullest allows the provider to spend more qualitative time with the patient to develop a solid care plan that meets their needs, along with the rapport and trust needed for patient engagement and adherence. Medical Assistants can also help the practice minimize unnecessary emergency department visits with things like high utilizer check-in calls, patient education, and even how to reach a provider with questions during the off hours instead of incurring an avoidable ED visit.

Invest in value-based coding

Fee-for-service coding and risk-based coding are different. Value-based reimbursement utilizes hierarchical condition codes (HCCs) (as opposed to Current Procedural Terminology (CPT) codes) to document patient conditions that drive reimbursement. Everyone in the practice—including your support staff—must understand how HCC coding and reimbursement works, the benefits of this model, how the model drives stronger clinical performance, and what’s needed from their roles to ensure success. To that end, investing in continuous education around value-based care and HCC coding is essential. For many providers, this is a significant departure from what they’ve done before, and it is not something they learned in school. Non-clinical staff must also understand the new approach and recognize their role in its successful implementation.

Practices may also consider embedding or outsourcing a certified risk-based coder. Risk-based coders are trained to partner with clinicians to ensure that documentation is sufficient and accurate across all the necessary elements for success in the event of a risk adjustment data validation (RADV) audit. Using fee-for-service coders for HCC coding could increase the likelihood that coding does not meet RADV standards, is less comprehensive, and this practice is not recommended.

Strengthen connections with the community

To fully manage the health of a patient population, physician practices must partner with the community. Integrating a social worker into your practice—either as a team member or a shared resource with other practices—can be highly beneficial. Social workers can foster strong relationships with community-based organizations that offer supplemental health services, such as diabetes support programs, healthy meal delivery, transportation services, and prescription drug discounts. In addition to serving as a community liaison, some social workers can support behavioral health counseling—especially in areas where behavioral health resources are scarce. This is advantageous, given the rising prevalence of behavioral health issues and their influence on the physical conditions the practice is trying to manage.

There’s no better time to pivot to a value-based mindset

Value-based care is rapidly becoming the mainstream approach for health care delivery and reimbursement. Physician practices that prioritize shifting their operations to enable early risk identification, team-based care management, robust documentation, and whole-person care are better positioned to thrive in the short- and long-term.

Tammy Schaeffer, RN, JD, is Principal at Plante Moran.