Steering Primary Care with Value-Based Reimbursement

May 07, 2019 By: Quadax

Many unknowns remain in the future of healthcare reimbursement; the best way to succeed is to ensure your revenue cycle is operating at peak efficiency. 

Primary Care Physicians often feel they’re running out of gas.  The value they provide is real: research shows significantly better healthcare access and experience for patients receiving primary care.  However, office visits to primary care physicians (PCPs) declined 18% from 2012 to 2016[i], suggesting that the value of PCP care is not widely acknowledged.  Meanwhile, physicians experience frustrations with administrative demands that encumber their ability to deliver needed care.

A JAMA Internal Medicine article reinforced the importance of primary care following a study of many thousands of US adults with and without primary care, concluding “policymakers and health system leaders seeking to improve value should consider increasing investment in primary care.”

Will the newly announced Primary Cares Initiative be the investment that makes a difference?

The American Academy of Family Physicians (AAFP) and America’s Physician Groups were among those applauding the CMS Primary Cares Initiative when it was announced on Monday, April 22, 2019. 

AAFP Vice Speaker Russell Kohl, MD said, "To truly unleash the power of primary care, we must do two things: Unhinge it from the episodic-based incentives of fee-for-service, and eliminate the administrative complexity of practice that distracts family physicians from patient care. In short, it has become clear that we must create payment models that support our desired delivery models."

Those distracting complexities cited by physicians in discussions of today’s greatest challenges include increased third-party administrative requirements, a rapidly changing reimbursement environment, and even measuring quality measure incentives and disincentives. 

Time spent with EHR data entry is a significant frustration, as well.  “EHRs were supposed to make patient records easily shareable among physicians. In theory, that would lead to more coordinated care and fewer medical errors,” says Sally Pipes, president, CEO, and Thomas W. Smith Fellow in Health Care Policy at the Pacific Research Institute in Forbes

“Instead, the mandate has been a bureaucratic nightmare. Doctors now spend half their time on EHRs and desk work -- and barely a quarter of their time with patients. In 2000, doctors spent more than 60% of their day providing medical care. The increasing bureaucratization of health care has left two in three doctors feeling burned out, depressed, or both.”

Enter the CMS Innovation Center and the Primary Cares Initiative, called “a major commitment advancing primary care in this country.”  Health and Human Services Secretary Alex Azar introduced the new value-based care initiative in a speech at the Washington office of the American Medical Association. 

The initiative comprises a set of five voluntary program models grouped into two paths: Primary Care First (PCF) and Direct Contracting (DC). PCF targets smaller practices, offering a general payment model and a second payment model for high-need populations. The three models in the DC path are Global, Professional, and Geographic; these target larger practices and are more ambitious.

The payment models incentivize participating providers to deliver advanced, patient-centered primary care services while keeping those patients healthy and out of the hospital.  They focus on value-driven, population-based metrics. 

In the PCF general model, population-based payments and flat primary care visit fees are meant to assist in the transition from fee-for-service to a value-based model.  Performance-based adjustments can reward providers up to 50% of revenue, or risk a 10% downside adjustment. Quality measures include acute hospital utilization in all 5 years of the program; starting in year 2, quality measures will include Patient Experience of Care Survey, control of hemoglobin A1c and hypertension, care plan, and colorectal screening. The Quality Gateway for practices serving high-risk and seriously ill populations will be developed during the model.

Data sharing is a key component of the program.  The plan for PCF data sharing is for participants to submit claims (with reduced documentation requirements) to CMS, and for CMS to return performance data to providers, to be used in their own analytic tools, so that providers may assess their own and their peers’ performance in the program to encourage continuous improvement.

Administrator Verma, in remarks to the National Association of Accountable Care Organizations, said, “Technology, and the sharing of data, underpin the entire move to innovative payment mechanisms.  Without effective, open data sharing, providers cannot keep patients healthy.  Without data to track patient progress or understand quality, payers cannot tie payment to outcomes.”  To this end, CMS is moving to modernize their processes for data sharing, encouraging APIs wherever possible.  The intent is for providers to “track their beneficiaries’ healthcare utilization and spending at a granular level, and then modify a patient’s care plan in response.”

The vision for value-based care is to both hold clinicians accountable for cost and quality while also giving them the flexibility to innovate—to provide quality, coordinated, appropriate care free from the dictates of bureaucracy and regulation.  Azar referenced the 4 Ps that are the goals of value-based care according to CMS:

  • Patients in control as consumers
  • Providers acting as accountable guides through the healthcare system
  • Payments based on outcomes
  • Preventing disease before it occurs or progresses

It’s not clear whether value-based payment models will automatically result in a complete system of value-based care delivery, though such an outcome would be good for both patients and physicians.  Reimbursement has been recognized as an effective steering wheel for the vehicle of healthcare delivery, however, so there is optimism for the results of this and subsequent initiatives.  Further, by encouraging multi-payer alignment, CMS hopes to retain firm control of the steering wheel.

Administrator Verma has indicated additional value-based payment models will be forthcoming, including programs for rural care, oncology, and other specialty physicians and surgeons.  She has also said future models are likely to be mandatory rather than voluntary. 

For the Primary Cares Initiative, participation is voluntary, and several conditions must be met in order to apply for the program.  The application process is expected to begin soon—“Spring 2019” according to the CMS timeline.  Qualifications for participation in PCF include geographic and demographic aspects, having experience with other value-based payment arrangements, using 2015 Edition Certified Electronic Health Record Technology (CEHRT), supporting data exchange with other providers and health systems via Application Programming Interface (API), and connecting to their regional health information exchange (HIE).  Practices must also comply with a set of “advanced primary care delivery capabilities,” such as providing 24/7 access for patients to practitioners. 

What does this mean for the business office?

Under a payment model such as PCF, claim processing will be different, but still vital. Hopefully, rejections and denials will be minimal, but it is unlikely payment discrepancies will disappear. Nor will the revenue cycle functions of patient access management, coding, cash application, etc. be rendered either inconsequential or obsolete.

Data tracking and analysis will become more important than ever to practices as they evaluate performance, innovate based on outcomes, and predict and confirm performance-based adjustments.

Data preparedness is associated with disaster readiness and response; it’s the “ability of organizations to…effectively deploy and manage data collection and analysis tools, techniques, and strategies in a specific operational context.”[ii]  In the context of value-based payment, data preparedness and ease with analytics capabilities is important for providers prior to joining a model, in order to confidently assume risk.  Understand your patient population, have a clear picture of costs and budgeting, and be ready to work with payment and performance data following model implementation. 

Many unknowns remain as we look to the future of healthcare reimbursement—of course, that’s nothing new.  What is known: the best way to succeed regardless of payment model (or variety of them) is to ensure all the parts of your revenue cycle are operating at peak efficiency.  When your staff enjoys greater productivity with cost-effective, connected tools for patient access, claims management, reimbursement management, and data analytics, you’ll be ready to hit the value-based road with confidence.

Quadax can help. Contact us to hear how we’ve helped both primary and specialty physician groups optimize their workflow and their cash flow. 

[i] Health Care Cost Institute, HCCI Brief: Trends in Primary Care Visits, October 2018

[ii] Nathaniel Raymond and Ziad Al Achkar, Data preparedness: connecting data, decision-making and humanitarian response, November 2016

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