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Driving Value Based Care Performance with Real Time Provider Insights

By John Zidansek

Health systems and provider networks continue to struggle financially with their employed physicians.   The Q3 average Investment/Subsidy per physician FTE increased to $231,654, an increase of 9.8% compared to Q3 2020 (Kaufman Hall Physician Flash Report, October 2021).  At the same time, work RVUs per physician increased 9.4% compared to Q3 2020.  Clearly it is time for health systems and provider networks to re-evaluate their utilization of legacy physician incentive models and embrace next generation value-based care reimbursement models to drive performance. 

Data proves essential in population health success. Providers must now make care decisions using near real-time, accurate, and impactful data to drive performance.  More complex data isn’t necessarily better.  For physicians it is all about precise, timely, actionable insights at the point of care for clinical decision making.  Through a data driven understanding of how and where providers can improve patient outcomes, physicians will engage to close care gaps where their current performance lags their peers, norms and expected metrics.

I have found that physicians are driven to change their performance primarily by two motivators:

Competition

I believe awards and recognition are more important to providers than many health system administrators realize.  Physicians are driven by a desire to excel and require constant feedback as to how they rank in comparison to peers.  They also consistently strive for top 5% performance.   Peer ranking and peer recognition are powerful tools when moving physicians toward value-based care and value-based care reimbursement.

We as non-clinical leaders need to rekindle the fire for competition with near real-time metrics that provide constant feedback as to how the physician is performing compared to peers and expected performance metrics.

Financial Incentives

Value based care reimbursement has rapidly grown to be a significant portion of total revenues for health systems and provider networks.  Organizations must plan to evolve from the long standing pay for volume work RVUs physician incentive models to align provider behavior to the organization’s goals in value-based care.

Health systems are now searching for ways to incentivize physicians for value-based care success by tying a portion of physician compensation to the accurate capture of disease burden or HCC performance metrics, Medicare annual wellness visits, and total cost of care metrics when operating within ACO or CIN organizations.

Where to begin – Real Time Provider Insights at the Point of Care

Annual Wellness Visits

The Medicare annual Wellness visit is the opportunity to increase evidence-based preventative care services for patients while increasing practice and health system revenues.  Medicare covers annual wellness visits at 100% and pays around $135/AWV.  The annual wellness visit generates around $400/AWV in downstream net revenues through diagnostic testing, E&M visits, vaccinations checks and disease screenings.  The annual wellness visit improves the accuracy of HCC related chronic diagnoses to drive higher risk adjusted factor scores and higher reimbursement rates for more complex/higher severity patients.

Despite the attempts to align CMS, health systems and providers to the same goal, the national annual wellness visit capture rate is only 24%.  To drive success with annual wellness visit performance, real time care gap identification at the point of care through advanced analytics and integrated data platform is essential.

Hierarchical Condition Categories (HCCs)

From a recent Advisory Board report, over one third of HCCs are not recorded or updated year over year (annual recapture) and many others are under-reported or lack specificity and have zero impact on risk adjusted factor scores or reimbursement.  Specificity gaps and missed capture of chronic conditions are most common with Diabetes, Chronic Kidney Disease, Congestive Heart Failure, Depression and Morbid Obesity.  If ICD 10 chronic condition codes are not supported with documentation and coded correctly and HCCs under-represent disease burden, reimbursements will drop and quality benchmarks are more challenging to achieve in shared savings programs. 

The best practice for success is to prepare providers ahead of the patient visit with a clear list or a Day Sheet/Work List of HCC coding opportunities (unsubmitted/annual recapture and unspecified).  Again, advanced analytics and an integrated data platform is essential for HCC performance success.

Cost and Utilization

Health systems and provider networks will need to review their readiness for value-based care through an assessment of their performance around cost and utilization performance metrics.  Leading indicators with readmissions and admissions, Emergency room utilization, access, transitional care management, diagnostic testing, post-acute care facility utilization, pharmacology, and referral management.  Following a thorough assessment of the organizations challenges and pain points, the best practice is to align the organization goals and performance priorities with the physician compensation incentive plan.  A reorientation from volume to value while holding physicians accountable for achieving the best outcomes while also avoiding unnecessary utilization or costs. 

To thrive in this rapidly changing environment physicians will require real time performance insights across organizational priorities to drive performance in value-based care.

Today, physicians and advanced practice providers are on overload with regulatory requirements, quality reporting, ever increasing payor requirements.  They are working in EHRs that have added tremendous burden on the shoulders of providers and have failed to simplify clinical workflows. The result is unprecedented burn out and dissatisfaction levels.  The challenge for health system and provider network leaders is how to identify and optimize value-based care opportunities through alignment with their physicians through advanced analytics, integrated real time insights for decision making at the point of care and through peer and organizational performance metrics aligned with incentive compensation and supported with clinical care redesign.

The most successful organizations in value-based care will begin their journey with a simple premise, how to cultivate the curious and competitive inherent nature of physicians through actionable performance data.