What We Know About Value-Based Care Under MACRA, MIPS and APMs

by Tony Tiefenthaler on Feb 28, 2018

physicians-financial.jpgPost-Acute Provider Networks Will Be Key Focus for Physicians Under Value-Based Reimbursement

“All alternative payment models and payment reforms that seek to deliver better care at lower cost share a common pathway for success: providers must make fundamental changes in their day-to-day operations that improve the quality and reduce the cost of health care.” That’s what CMS said when it announced its VBR adoption targets in January 2015.

Perhaps no one, let alone those most responsible for hitting these targets, knew exactly what that meant at the time. Some two years later, the realization has come that the need for fundamental change was an understatement.

Today, physicians entering value-based reimbursement models stand to be financially impacted by outcomes they can’t always oversee or control, identifying the need for systems that monitor patients throughout the entire continuum, not just the portion of care for which the provider has physical access to the patient.

As a result, physicians will likely demand tighter management of the post-acute space to ensure they receive the total financial benefit under VBP. Of course, managing and nurturing a high-performing post-acute network can’t take place without practice workflow improvements that enable processes ­– such as technology-enabled care coordination and shared decision-making – to ensure that they effectively benefit (or are at least not penalized) under MACRA.

The continuity gap that currently exists between acute and post-acute settings is an important factor to be considered when trying to mitigate financial risk under VBP and this fact isn’t lost on physicians struggling to adapt to the new value-based world. According to a survey of 600 members of the American Academy of Family Physicians (AAFP), 86% said coordination of patient care is a key success factor for VBP success.

For hospitals, it means gaining visibility into lower-acuity settings so they may analyze and predict which post-acute providers offer the best services for the dollar spent. Even though limited data can make it difficult to compare quality, safety and affordability across facilities, smart organizations are finding ways to do just that. Value-based reimbursement demands that disparate facilities connect at various points along the continuum of care. Technology and communication solutions, shared staffing arrangements, contractual relationships, narrow networks and acquisition strategies to align referrals with high-performing entities must be a part of the conversation.

Hospitals that fail to get a grasp on their post-acute care (PAC) network performance stand to lose doubly – in dollars and cents in their own VBP reimbursements and in reduction in hospital referrals as doctors naturally migrate their patients toward hospitals with higher-performing post-acute partners.

Gone are the days when post-acute care providers could be considered simply as a downstream referral partner. New value-based payment models incentivize acute care and PAC providers to work together to improve care coordination, quality and cost efficiency. As hospitals and physicians begin to share clinical and financial risk for patients, it will serve both to take a vested interest in network facilities’ performance.

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Meet the Author

A seasoned leader who has a broad and diverse background with over 30 years of experience in the payer and provider space. Led the development and provided key leadership of a startup Clinically Integrated Network (CIN). Also has executive level experience in an integrated delivery system and has held leadership roles within the clinic, strategy office and health plan. Developed and implemented a Medical Home and Behavioral Health care management models and has expertise in contracting with payers on value based care, bundled payments and established employer-based primary care clinics. Acknowledges and promotes the importance of data analytics to monitor network and program performance. Ongoing communication, relationships building and physician engagement are essential to the success of an organization.


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