Medical Billing Services

Preparing Your Practice for Value-Based Care

What is Value-Based Care?

Unlike traditional ‘fee-for-service care models that link payment to the number and type of services utilized, value-based healthcare is a health care delivery model in which providers, including hospitals and physicians, are paid based on patient health outcomes. Value-based care differs from a fee-for-service or capitated approach, in which providers are paid based on the number of healthcare services they deliver. The ‘value’ in value-based healthcare is derived from measuring health outcomes against the cost of delivering the outcomes. Under value-based care agreements, providers are rewarded for helping patients improve their health, reduce the effects and incidence of chronic disease, and live healthier lives in an evidence-based way. The following four steps will help you in preparing your practice for value-based care. 

1. Identify Your Patient Population and Opportunity.

Knowing your patients is the foundation of value-based care. Patient populations with the highest risk of hospitalization or high utilization of the emergency department (ED) tend to drive high health care costs and most often receive fragmented care. These populations often include poly-chronic patients – those with chronic and complex conditions with multiple co-morbidities, such as diabetes, hypertension, depression, heart failure, cancer, kidney failure, or chronic obstructive pulmonary disease. Understanding which patients drive your highest cost of care and those who use the ED frequently will help you to identify your target population and opportunities for improvement. Once you have this information, you can begin to develop your model.

2. Design the Care Model.

Develop care models that are evidence-based and easy to follow. You can consider the following elements in the development of your value-based care model:

  • Identify the target patient population(s).
  • Identify which payers will be involved.
  • Estimate how the type and volume of services will change. Involve your legal advisors at the outset so you are aware of and design the program in compliance with federal and state laws.
  • Identify the benefits expected for patients and payers.
  • Design the workflows required to provide the desired care to the selected patient population.
  • Discuss details including:
    • Team members who will support the new model.
    • Roles and responsibilities of each physician and the care team.
    • Frequency of patient contact (via phone call, email, or portal messaging).
    • Frequency of patient visits to the practice or from home health care.
  • Identify measurable success metrics for each population, and determine your baseline in order to quantify your impact in the future. Your metrics should be easy to capture in the electronic health record (EHR) or population health registry to prevent having to extract them manually.
  • Identify transition costs (as a note, revenue needs to be addressed as well as risk-stratification).

Depending on the licensure, education, and training of your team, current team members could potentially fill the staffing needs of the new value-based care model with proper education and redistribution of responsibilities. Utilizing current staff can be cost-effective during the initial transition period, but additional staff may be needed as the model continues to be adopted by the practice, particularly since value-based models rely heavily on effective care coordination and require a greater amount of data capture and analytics.

3. Partner for Success

Coordination with local hospitals, practices, urgent care centers, insurers, or other organizations may enhance your ability to offer better transitional care and outpatient care management to your patients. Multi-provider arrangements should be considered with legal advisors. Care fragmentation poses a major safety risk and can lead to patient dissatisfaction and disengagement. The hospital-practice collaboration is an opportunity to decrease care fragmentation through coordination and communication. A hospital collaborator may be able to provide discharge lists and ED visit reports that can help your practice follow up with patients and ensure continuity of care.

4. Quantify Impact and Continuously Improve

Continuously monitoring your progress will help you determine the impact you have on your target patient population. To achieve positive outcomes, reassess how well your practice is accomplishing the predetermined goals monthly or quarterly, and adjust your efforts as needed.  Each step on your journey to value-based care is a learning experience. Some decisions will work well, and some ideas will not work as planned. As these experiences provide your practice with more knowledge about what works best, the practice can make the changes that will better meet patient needs. Transparently and routinely informing your practice of the results of the value-based care model implementation, either in scheduled team meetings or with brief recaps during huddles, can help encourage the team to stay positive so they can continue to deliver value to patients.

We hope that this article has given you to get started with preparing for value-based care. For more information on value-based care and its successful implementation, you can visit the AMA website. MedicalBillersandCoders (MBC) is a leading provider of medical billing and coding services. Our billing and coding expertise over various medical specialties ensures quick and accurate insurance reimbursements. To get the latest updates on medical billing and coding, subscribe to our newsletter or visit our latest blog section.

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