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Actively Manage Commercial Value-Based Care Contracts

Explore How Top-Performers Use Information to Actively Manage Commercial Value-Based Care Contracts

Wouldn’t you like to get out ahead of your commercial value-based payment contracts and be more proactive?

Providers find that value-based contracts are responsible for an increasing share of their revenue. As these programs mature and evolve, we believe payment amounts tied to VBPA will increase. In fact, commercial Value-based contracts are expected to account for 59 percent of all healthcare payments by 2020. In 2017, Forbes reported that Anthem’s value-based care model payments were close to 60%.

The challenge

First, none of your clinical information are considered in the payer’s quality measurement calculation. They make all their assumptions and calculations from claims info. As a result, you are working with a very one-sided arrangement, and it’s not in your favor!

Second, it is not until long after you’ve seen the patient, incurred the overhead costs and paid the salaries, that you are able to see what you gain from these contracts, and by then it’s too late to make any changes.

Wouldn’t you like to get out ahead of your commercial value-based payment contracts and be more proactive?

Wouldn’t you like to be able to monitor and improve clinical-quality performance close to the time of care?

For practices wanting maximum reimbursement for their quality care, it’s necessary to augment the claims information with clinical quality information.

In order to gain a 360-degree view, there are a number of critical issues to consider.

Clinical Performance Data

Accurate performance data is essential to success with a pay-for-performance contract. If a payer has created a data dashboard, you can see their view of information, which is entirely based on claims. While this data is helpful and directionally informative, claims-based data is only one side of the story and does not paint a clear picture of the care. For instance, it doesn’t include any activity that wasn’t included in, or didn’t generate a claim. Keep in mind that raw claims data alone is unlikely to be sufficient for purposes of tracking and optimizing your clinical performance in the model.

If your payer doesn’t provide a dashboard, there are alternative mechanisms for access to data. While real-time access to an online portal is ideal, the important thing is that there is some system in place to help you manage and understand the data upon which the payer is considering and measuring performance.

Think how much more powerful your next negotiation will be!

Quality measures

Pay-for-performance agreements often document the specifics of measure development and the calculation and determination of measure performance.

Some payers use their own measures but base them on their own interpretation of nationally accepted measure sets. For example, Blue Cross Blue Shield of Massachusetts has its own measures for its Alternative Quality Contract program, but bases them on well-known, national measures.

These benchmarks, met/not-met criteria, triggers and qualifying events can vary from plan-to-plan and are different from those CMS uses in the MIPS Program.

The important thing here is that you have a solution in place so that you can measure and monitor your performance in every program and for every eligible clinical event.

Actionable Information

Understanding and exceeding the clinical-quality measures used by each plan or contract is obviously critical to success with these programs. But be cautious not to overlook the larger picture view of how these measures dovetail with measures in your other value-based care programs. Finely-tuned practices will actively manage quality measures across all their contracts and track performance against each of their respective benchmarks – while tuning their clinical behaviors to achieve the most restrictive of measures.

Some groups are working for the healthcare industry to adopt a standard set of measurements for pay for performance models with longstanding capacity and reduced redundancy. However, with the absence of standard measurements, you need clinical-performance analytic solutions that are flexible and transparent.

ReportingMD offers solutions and service backed by 16-Years’ experience in managing and optimizing clinical value-based care programs.

At ReportingMD we provide a measure driven outcome management solution called Total Outcomes Management (TOM™). Using TOM™, providers have operational visibility into the clinical outcomes within their patient population.

With the rapid increase of pay-for-performance agreements with commercial payers, our clients use TOM™ to manage, monitor and measure clinical quality performance of every payer contract, with measures specifically tuned to the requirements of each program.

TOM™ gives you the information you need to manage effectively

  • Aggregate claims data and payer data into a single dashboard
  • Monitor performance for all programs, from a single dashboard, simultaneously
  • Compatible with most EHR and PMS Systems
  • See performance across all clinical quality measures
    • Using standard or custom benchmarks
    • See performance specific to individual plans
    • Choose from more than 400 quality measures
  • Visibility through to the individual patient encounter
    • See performance by provider and location
    • Identify care-gaps to the individual patient encounter
  • Provides a clinical-quality performance audit trail

Our clients engage ReportingMD’s technology, backed by our expert support, to improve population health outcomes, optimize clinical performance score and enhance revenue.

Find out if we can help you.

Schedule a Demo or Request More Information


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