Insurance / PayerPayment ModelsRevenue Cycle Management (RCM)

Key Takeaways For Physicians From Value-Based Reimbursement

In the rapidly changing healthcare landscape, payers are asking medical providers to shift from volume-based care; the fee for service to a value-based reimbursement structure. This evolution toward value-based reimbursement benefits the patient, the healthcare provider as well as the payers. Value-based reimbursement encourages healthcare providers to deliver the best care at the lowest cost. In turn, patients receive a higher quality of care at a better value.

Because of the continued focus on value-based reimbursement, these regulations will have a financial impact on the healthcare industry all across the U.S.A. For this article, we are going to focus on the key takeaways for physicians from value-based reimbursements:

  • A certain amount of scale is required for success. Whether an ACO is hospital-led or physician-led, it needs deep pockets to build the necessary infrastructure and hire sufficient care managers.
  • Physicians will have to become accustomed to the idea of delivering high-quality care within a budget.
  • Restructure physician comp to align provider incentives with value-based care.
  • Create patient-centered medical homes or use existing PCMH as building blocks for your ACO.
  • Focus on care management for high-risk patients as well as other segments of the population that could become high risk in the future
  • Automate as much of population health management as you can while emphasizing human contact for high-risk patients
  • Assimilate claims data with clinical data to provide breadth, timeliness, and adequate detail for analytic purposes.
  • Find ways to obtain timely information from hospitals and health plans about admissions, discharges, and procedures
  • Use predictive modeling to intervene with patients who are likely to get sick in the coming year.
  • Use registries to track patients’ health status and make sure they get the services they need.
  • Apply financial analytics to budgeting, using historical data on costs and, if possible, activity-based cost accounting.

Public and private payers, including Medicare and some of the nation’s biggest health insurers, plan to hasten the migration of the healthcare reimbursement system from pay-for-volume to pay-for-value. The acceleration in the pace of change from fee for service to risk-based reimbursement is likely to reshape the healthcare business over the next 3 to 5 years.

While all healthcare stakeholders will be affected, the pioneers of this approach to healthcare financing will be large, integrated delivery systems and accountable care organizations. Some of these organizations already take varying amounts of financial risk, but the percentage of their revenues coming from shared savings, bundled payments, and global or partial capitation is certain to rise in the next few years.

To prepare for these imminent changes, these organizations must rethink their near-term financial and clinical strategies. They must consider not only how to make the transition to new payment models, but also how to maximize their reimbursement in the new world of population health management. A key part of their strategies will be medical billing which will continue to evolve in tandem with the changing reimbursement landscape.

Value-Based Reimbursement Is To Stay

The healthcare industry has gone through a lot of changes, updates, and new reporting measures. And they’ll only continue as CMS and other payers work through the challenges to improve care through various improvement programs. But; as the penalties increase, health systems will be at a disadvantage if they don’t work to improve the quality of care they provide. In fact, these reductions can exceed the average margin for most hospital systems and cause significant financial hardships.

To be able to survive the value-based reimbursement model, medical coding, medical billing systems need to access their data to determine where they can improve. But most current healthcare data models can’t support the need to analyze data and pull reports from the many different source systems that have already been purchased. Instead, health systems need something different a systematic approach that uses the right information and the right processes at a system level to drive improvement.

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