There’s been a lot of discussion about reforming our health care system over many generations and presidential administrations, and most recently in the run-up to and immediate period after the election of Donald Trump. Republicans promised for 7 years to repeal and replace Obamacare only to (so-far) fail miserably at walking-the-walk.  I believe the political milieu, is at best a red herring, innocuous and really noise.  The fact is the value movement that we’re talking about in health care is really a market movement.  The proverbial train has left the station and market principals are already starting to disrupt the industry.

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Quality. Cost. Patient Satisfaction.

There are the three main areas in which physicians will be measured, as our healthcare system shifts from volume to value. The Centers for Medicare and Medicaid Services (CMS) has already begun tying reimbursement to these measures, and commercial payers are creating similar, value-based models.

In a previous post, we discussed how doctors can succeed under the new quality metrics. Here, we’ll explain how physicians can meet cost benchmarks.

Defining “cost”

The cost that’s relevant to payers is the annual amount spent by patients and their insurance providers for the patients’ care. It is not the provider’s cost of doing business, such as overhead costs. Moreover, “cost” is the total amount received by all of a patient’s providers.

To illustrate: Dr. Smith is a primary care physician with 100 attributed patients. He received $10,000 for their care. Dr. Smith’s patients also spent $90,000 with other providers. Therefore, Dr. Smith’s cost of care is $100,000.

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As our healthcare system shifts from fee-for-service to value-based reimbursement, physicians face increasing requirements to report on the quality of the care they provide.The Centers for Medicare and Medicaid Services (CMS) has established a complex system of financial rewards and penalties tied to quality and costs of care. And commercial payers are starting to follow suit. For these reasons, doctors need to understand the quality metrics against which their performance will be measured, and how to optimize the quality results they report.

Under the Group Practice Reporting Option (GPRO) Web Interface, CMS requires primary care physicians to report annually on several point-of-care measures – from how many patients received flu vaccines, to the number screened for colorectal cancer. 

Know the requirements

On the plus side, most doctors already provide high-quality, evidence-based medicine. Where they typically fall short is in understanding the requirements for meeting the quality standards -- including proper documentation.

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