Physicians must code diagnoses properly to succeed under Medicare Advantage & other value-based contracts
Each year, CMS sets cost benchmarks for every Medicare Advantage member, based on the patients’ diagnoses during the prior year. But what if the physician hasn’t reported their patients’ health information accurately or fully? The result is often benchmarks that are set too low, and costs of care exceeding benchmarks.
The payer then thinks the doctor spent too much on members’ care, and does not recognize or reward the value (high quality/lower cost) of the care provided by the physician.
That's why proper Medicare Risk coding—entering diagnosis codes in the EMR and on claims—is essential. Providers who follow best practices for risk coding have a better chance of earning shared savings.
With the growing complexity of the healthcare industry, practicing physicians are seeing an unavoidable rise in required reporting and administrative tasks. At the same time, the increasing financial burden of maintaining a viable practice weighs heavily on providers. These mounting pressures cause high levels of stress, frustration, and fatigue, leading to physician burnout.
The number of High Deductible Health Plans (HDHPs) and Consumer-Directed Health Plans (CDHPs) in the market continues to increase as patients and employers look for lower monthly premiums and payers aim to place more financial risk on patients.
In 2016, the Kaiser Family Foundation reported that an average of 51 percent of workers were covered by a health plan with an annual deductible over $1,000 for single coverage. This group of individuals had increased by 22 percent since 2009, and this trend continues to rise.1 With high deductible plans, patients are often liable for the entire cost of the payer negotiated rate of their physician visit, and the high out-of-pocket expenses are driving them to make savvier healthcare decisions. Patients desire more financial transparency, access to healthcare costs, and increased communication from their provider. Yet despite patients’ increased financial awareness regarding their obligations, many are still unreliable payers in the market.
Revenue Cycle Management,
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2018 is expected to be another tumultuous year for the healthcare industry, even though industry growth is projected to remain mostly stable.1 With the repeal of the Affordable Care Act (ACA)’s individual mandate, uncertain policy efforts to strengthen state marketplaces, and ever-increasing insurance premiums, there will be a broad range of challenges facing the industry this year.
Yet for physicians and clinicians, the industry’s shifting tides will not be the center focus. Physicians will place increased emphasis on alleviating operational challenges, improving the quality of care for their patients, and tracking compliance with care plans to improve patient outcomes. These improvements are expected to aid in the decrease of overall healthcare spend, since industry trends in 2018 will focus on innovative ways to lower costs, increase quality, and reduce unnecessary utilization.
2018 healthcare trends,
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Though telemedicine has been a segment of the healthcare industry for years, the use of telehealth technology has not expanded to meet its full potential. Telemedicine still has a few challenges to overcome, the biggest being the lack of strong financial incentives for implementation and utilization—despite telehealth’s capacity to lower overall healthcare usage and save time for providers.
The healthcare industry lacks a unifying drive to incorporate telemedicine into physicians’ day to day routines, since in many states providers are not reimbursed for tele-visits at the same rate as in-person visits. Continuum Health's CMO, Dr. Michael Renzi, recently wrote on his difficulty embracing telemedicine due to a continuing need for fee-for-service payments. Though telemedicine offers great opportunities for practices, it is stymied by the lack of proper reimbursement.
Yet with the volatility surrounding healthcare policy under the Trump administration, there is hope that new or further developed healthcare legislation could incentivize telemedicine for providers, helping them to achieve the Triple Aim.
Today’s patients have numerous choices of hospitals, urgent care, and other ambulatory care centers when they seek treatment. While primary care providers (PCPs) can typically help patients with these decisions, patients sometimes visit these facilities before consulting their PCPs for treatment or preventative care. Expensive hospital visits can drive up healthcare costs and have a negative impact on quality overall—but fortunately, PCPs have some options to help keep costs down.
PCPs lower healthcare utilization
Independent PCPs emphasize quality of care through their personalized interactions and relationships with their patients. When PCPs are readily available in a community, patients are less likely to seek treatment at a specialized facility, hospital, or urgent care center.1 Unnecessary emergency room visits are a drain on the nation’s healthcare system when the source of the visit could have been treated or prevented by a primary care provider.
PCPs focus on establishing a rapport with their entire patient population. These relationships allow doctors to draw conclusions about a patient’s overall health or potential illnesses on an ongoing basis. Consistent, meaningful visits build a bond between patient and provider, which encourages the patient to seek treatment from his or her PCP over a hospital physician.
cost of care,
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Primary Care Providers
Is employment really the answer?
Hospital employment, with its promises of financial security, fewer administrative duties, and more stable working hours offer a strong case for physicians. From 2007 to 2016, the number of independent physicians has decreased by 28 percent.1,2 Many physicians have opted for employment within a large health organization because it appears more appealing than fighting to maintain an independent practice; but the number of physicians pushing for independence may be on the rise.
This shift is being triggered as physicians find those promises aren’t always grounded in reality. Physicians feel that an employed position will require less administrative tasks and thereby provide more time to spend with patients. Yet administrative duties are inescapable. Most physicians are still required to maintain quality of care reporting and accurate EHR entries, whether they are independent or employed.
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As many physicians are aware, major changes are underway in how Medicare will reimburse them. The Centers for Medicare and Medicaid Services (CMS) is phasing in new reporting requirements focusing on “value” of care: measures of quality, overall cost of care, and patient satisfaction. Increasingly, how doctors address these new requirements will directly affect their reimbursement – potentially leading to financial rewards or penalties. Moreover, commercial payers are starting to follow Medicare’s lead.
Here’s a quick refresher on the basics, including important dates for most physicians who see Medicare patients:
- The Medicare Access & CHIP Authorization Act (MACRA) of 2015 requires doctors to choose a reporting path – either the Merit-Based Incentive Payment System (MIPS) or an Advanced Alternative Payment Model (Advanced APM).
- MIPS is comprised of Quality, Improvement Activities, Advancing Care Information, and Cost. MIPS payment adjustments will start at +/-4% for the 2017 reporting year (2019 payment year) and increase over time. (Cost will not affect payment adjustments until 2018).
- Advanced APMs offer higher financial incentives than the MIPS track, but require more advanced levels of value-based activities. APMs also require physicians to be part of a larger group, such as an accountable care organization (ACO) or medical home, and to bear greater financial risk.
Despite helping reduce costs, are narrow networks the true way of the future?
It's time for a change. As limited provider choice in exchanges rises, and the need to track quality across the patient’s care delivery continuum creates a bigger impact on providers’ bottom lines, practices will need to find means to protect their revenue. This is forcing more and more provider organizations to develop preferred partner lists—another way of saying narrow networks.
There are two key groups impacted by this shift, and they seem to have different feelings about the pros and cons of narrow networks.
- Patient benefits: The healthcare industry can expect to see more narrowing as time goes on. This is, in part, thanks to the benefits to healthcare consumers. Narrow networks offer cheaper premiums—on average, those premiums are 17 percent less than plans with broader networks.[i] In fact, nearly 70 percent of the lowest priced plans are built around narrow networks, ultra narrow networks, and tiered narrow networks.[ii] The downside, though, is higher prices for out-of-network costs—which were, on average, 300 percent higher than the average Medicare rates for 97 common medical procedures.[iii]
- Provider concerns: This trend is causing some anxiety amongst providers, and for a couple of different reasons. Providers’ ability to retain their patients may be challenged if their system of narrow networks is not clearly defined. In addition, providers may not have a clear understanding of how their participation or performance will be measured—or what may cause them not to be invited to participate in an ultra-narrow network.
The healthcare payment landscape seems to change every week. Developing a strategy for success is nearly as tough as assessing what alternative payment model (APM) programs you should pursue. Is there a benefit to staying focused on
fee-for-service? Are pay-for-performance models the right path for your organization? How much risk is too much risk for you?
The good news is there’s no one path to value-based care success. The various programs offer different benefits to healthcare organizations of all types. Understanding the full ecosystem of programs available to you is critical to make sure you start your journey to future success on the right path.
As with any journey, keeping a guide handy is a smart plan. Continuum’s value-based payment experts have developed a new reference to help you make sure you’re on the right track. This infographic, “The Trail Guide to Value-Based Care Success,” offers key insights and reminders about the benefits for various payment programs, common challenges, and tips for making the most of your participation.