Evolving models of care: Preparing for value-based payments

We have reached the tipping point, and all roads lead to healthcare reform. Health plans, government programs, employers and organizations of all sizes, shapes and values are working together to transform the U.S healthcare system into one of the new models that yield consistently higher-quality care while stemming costs. While healthcare is delivered locally and every population has its own health needs, education levels, economic profiles and cultural attributes, key components impact the business of the new healthcare models regardless of where they are located. Here are a few of those key components for which your practice must prepare:

1. Recalibrating compensation methods to reward clinicians and staff who deliver safe, efficient and high-quality care. This shift will require new data sources. Payment models will move away from traditional fee-for service reimbursement to payments based on value, introducing more incentives for cost efficiency and meeting outcome metrics. The Medical Economics Reader’s Rector Survey poll showed concern over new reimbursement models as the biggest challenge in 2016 and beyond. The questions surrounding the Centers for Medicare & Medicaid Services (CMS) merit-based incentive payment system (MIPS) for part B payments were:

“How will the Centers for Medicare & Medicaid Services (CMS) determine physician scores under MIPS, which requires a zero to 100 composite score?
At what level will scoring take place? By practice or by individual doctors?

Will the new pay-for-performance focus drive more doctors into alternative payment models (APMs) such as accountable care organizations (ACOs) and patient-centered medical homes (PCMHs)”?

2. Instilling accountability across the care continuum to increase coordination among all parties involved in providing care (including patient hand-offs), in whatever settings care is delivered. Care coordination and management across the continuum will reduce emergency room visits and prevent hospitalizations and re-hospitalizations. While practices must assume greater risk, with that risk comes greater control over decision making. This fact alone could be a major theoretical shift in most practices. With at-risk payments or even episodes or bundles, care decisions will reside not with the payer but with clinicians. Care plans and care pathways will become increasingly important to maintain consistency and avoid over- or underuse in treatment options.

3. Mastering the metrics. Clinicians will get unexceptional results if they don’t enter every visit mindful of metrics. Practices must challenge themselves, staff and patients to continuously improve.

4. Engaging consumers, understanding patient activation by providing them with the right amount and level of information so they can make informed decisions and more actively participate.

Changing models to improve the healthcare system and the health of our populations requires a commitment to ongoing collaboration. This collaboration is not just between payers and providers in traditional hospital and physician settings, but also in local communities and among individuals, employers and other supporters of care. The collective impact will bring about new models that yield consistently higher-quality care while stemming costs.

If you have questions about staffing or need additional help, contact Pamela Ballou-Nelson at pballounelson@mgma.com.