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Get health IT ready for value-based reimbursement


From the vendor for billing and collections software, to an EHR, if physicians have the need to succeed in value-based reimbursement, help is available.

Hopefully by now, a practice's electronic health record (EHR) system may feel like a member of the "family." Now it's time to adapt it to value-based reimbursement.

To make sure this happens, Hunter Sinclair, senior engagement manager in Advisory Board’s consulting practice, offers the following advice:

1. IT vendors (really) can do more.

Many IT vendors have, thankfully, stepped up their games. Early adopters of value-based reimbursement had to build custom dashboards to track quality measures in their EHR, but these now come built “out of the box." Some EHR vendors provide accurate documentation of codes needed for risk adjustment as an essential function. The least expensive vendor during the push for Meaningful Use may not be enough in this value-based environment.

The practice's vendor should provide as much visibility as possible around quality measures, showing gaps in care and in risk-adjustment coding. The EHR should exceed the minimum requirement to receive incentive payments, coordinating patients’ care with other providers, especially those with a different EHR. It's important to understand vendor capabilities around e-prescribing, communication with health information exchanges and participation in national pushes for interoperability such as the CommonWell Health Alliance.

2. Thankfully, there's limited impact to billing and collections.

Most value-based contracts are built on the current fee-for-service environment, so most existing billing and collections providers must meet basic needs for fee-for-service and value-based reimbursement, Sinclair says. Billing and coding software should enable the practice to get credit for quality measure performance. In value-based care contracts where quality measure performance is calculated off of claims, practices want credit for giving that flu shot, for example.

While limited upgrades are required for billing and collections software, those negotiating value-based contracts need to communicate any impact to finances to billing and collections leadership. Value-based payment programs like Comprehensive Primary Care Plus (CPC+) sometimes have a structural element that reduces fee-for-service payments in exchange for partially capitated payments. This could complicate financial tracking software.

3. Clear communication of contract details is critical.

Every practice has a different contract with its IT vendor. Communication lines may differ between population health staff and the IT tech that negotiated the contract. Staff may not totally understand what the system can or can't do within the practice's existing relationship, and may not grasp the need for additional add-ons. The physician or the staffer in charge of population health can closely communicate with everyone else on staff so they can articulate what's needed in terms of IT, especially around risk-based contracts.

4. Mind the gap.

The biggest "gap" for providers seems to be risk adjustment documentation, says Sinclair. They need more visibility into how a patient’s problem list is or is not reflected in claims. Document that a patient has diabetes this year to get credit for that patient’s acuity next year in a risk-based contract. Say "This patient had [this chronic condition] and it's not going away" to get measured based on the patient’s full acuity.

In fee-for-service markets, providers may document conditions prompting a patient's visit, but not when the patient also has COPD and congestive heart failure.

Accurate coding translates to credit for acuity of patients. Organizations may “succeed” at population health by drastically lowering preventable admissions and ED visits. They didn’t get credit under their contracts because of poor documentation of patients' conditions. In a risk-based world, practices deserve credit for the complexities of their patients.

5. Look ahead now.

Medicare payment reform (also known as the Quality Payment Program) brings value-based care to every provider so it’s best not to be complacent. This payment impact lags two years after the measurement period. A practice could do poorly for two whole years-2017 and 2018-before anyone notices a financial impact. Then staff realizes how much work is needed to improve performance, but by then it may be too late. True, IT investments take years to yield results, so be proactive versus reactive. Remember that commercial payers follow closely what Medicare does.


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