As the healthcare industry continues its path toward digital transformation, value-based care (VBC) models are also maturing to entice more providers to shift from a fee-for-service payment model to a pay-for-performance one. VBC creates more opportunities for providers to enhance their patient care and bring in new revenues from reimbursements.
Medicare has been pushing for VBC by adding more billable codes and increasing reimbursement rates. Yet, research shows that many providers are underutilizing these codes and unable to fully maximize the incentives that were designed for them. Though there have been small increases in VBC payments, uptake is still considered slow despite the benefits tied to the program.
So why are physicians reluctant to fully embrace value-based care?
Interest vs. Risk
An estimated 80% of physicians are interested in adopting value-based care programs according to Bain’s recent Frontline of Healthcare survey. However, this interest goes down when there is an increase in the level of risk to the providers.
Value-based care focuses on patient outcomes and incentivizes providers based on their performance measures in preventing escalations that merit an ER visit, inpatient readmission, or hospitalization. In the same manner, providers are penalized when they fail to meet the required performance measures, which presents risks that could offset any cost-savings they would incur from participating in VBC arrangements.
The recent July 2022 Bain survey confirms that physicians’ interest in VBC is inversely proportional to the risks they are willing to take. Hence, interest declines as the risk increases as seen in the following figures:
- 50% of physicians are interested in pay for performance or quality incentive payments;
- 27% in shared savings for upside risk only;
- 21% for an episode of care or one fee for care from diagnosis through treatment;
- 17% for both upside and downside risks;
- 16% for partial capitation or bundled payments; and
- 13% for full capitation.
There is evidently a mismatch between payers and providers with the former pushing for more cost-savings and the latter only willing to take on upside risks, which means sharing in the savings and not the risk of loss. Based on the study by the Health Care Payment Learning & Action Network, two-sided risk-based payments only account for less than 20% of total VBC payments that include both upside and downside financial risk, which means sharing in both savings and potential losses.
Physicians have reason to be concerned about their capacity to take on risks. The Bain survey disclosed that physicians continue to face barriers financially, operationally, and administratively to fully embrace VBC. Physicians understand how difficult it is to succeed in VBC models and at present, most feel less equipped to embark on a new care model compared to the sentiments they shared in previous surveys back in 2017 and 2020.
What can be done to push more physicians toward VBC?
Hurdling the barriers
The same Bain survey looked into what would compel physicians to adopt VBC. These are what the survey discovered:
- 37% of physicians cite more sufficient financial resources;
- 32% seek effective medical coding and billing processes to navigate the complexity of Medicare regulations; and
- 29% need additional staff to manage the reporting and outreach requirements of VBC.
Physicians know that there is a substantial capital investment needed to start a VBC program. A practice would need to invest in new software or technology, build the required infrastructure, have the capability to understand fully the billing requirements, and hire new personnel to be part of the clinical team. Without these essential elements, the physician will not be able to fully maximize the rewards of participating in VBC contracts.
What solution can help physicians get started with VBC?
There is one VBC solution that physicians seem to overlook and yet many of them are already providing these non-face-to-face services without billing for it. Primary care physicians can utilize Chronic Care Management (CCM) which is a Medicare service for patients with two or more chronic conditions. Through CCM, physicians can benefit from a VBC arrangement and mitigate its risks.
CCM improves patient outcomes
CCM improves patient outcomes because it provides multiple touchpoints in-between office visits to ensure compliance with the care plan, adherence to the medications, keeping up appointments with other providers, and following other vital care instructions.
CCM also utilizes an effective patient engagement methodology through care coaches who call the patients regularly and provide additional support for them to better manage their care. The insights gathered by the care coaches aid clinicians in making timely changes to the trajectory of care and prevent possible escalations or costly hospitalizations.
Incidentally, CCM is best paired with Remote Patient Monitoring (RPM), which utilizes telecommunications technologies through wearables and at-home devices that capture patient data in near real-time.
CCM keeps many chronic care patients healthy and out of the hospitals thereby improving the performance metrics of providers who care for them and avoiding penalties that could result in losses.
To overcome the barriers in terms of resources, capabilities, and staffing, practices can opt to partner with third-party partners.
Partnering with third-party experts
CCM can be outsourced to a third-party partner with the resources and capabilities to set up a practice within minutes. Delegating capabilities to third-party experts is the most logical solution to overcome financial and operational hurdles.
This is the most popular option, particularly when there are several parties involved in handling sensitive data and information as well as for smaller practices to effectively manage costs. This kind of partnership is successful when the Service Level Agreement measures the vendor’s performance and quality of service and is not just a simple contract that states legal obligations.
This may entail a reimbursement split, which is still advantageous to the practice as they avoid the pitfalls of starting their own not only in terms of increased overhead but also disruptions to the workflows. Also, CCM can be easily scaled up so the reimbursements will amount to a considerable amount of new income that goes straight to the bottom line.
Addressing physician concerns
Ascent Care Partners (ACP) can fully meet the requirements of practices so they can finally shift towards value-based care. Practices can now leverage our resources, our capabilities in understanding the intricate billing requirements, and our clinical team as an extension of their own care team to manage the program. We provide turnkey CCM and RPM solutions helping practices with patient enrollment up to the preparation of billing charges at no upfront cost or setup fees.
We work with the following providers:
- Primary Care Physicians
- Family Practice Physicians
- Internists
- Physician Assistants
- Nurse Practitioners
- Gerontologists
- Non-Interventional Cardiologists
- Endocrinologists
- Wound Care Doctors
- and other providers
