Value-Based Care is a natural movement toward the benefit of the patient with a reduction in costs by aligning all incentives in the right direction. And as providers make the shift, patients will be encouraged both by the motive behind the transition as well as the improvement in their overall health and the reduction in the costs of their care. Truly, Value-Based Care has the potential to be a significant win-win for patients and providers. And in the end, isn’t that why you spent all those years pursuing your medical training? Value-Based Care is for patients, and for the providers who care for them.
The market is now moving towards building value-based care drivers to all types of patients outside of Medicare Advantage. It’s unlikely a brand new risk model will be born for commercial patients. Therefore, all physicians will need to understand the risk adjustment models and the implications of documentation accuracy for reimbursement.
Why is HCC Coding Important for Value-Based Care?
HCC coding’s importance is less about the impact on revenue and more about the shift towards VBC models, which have consistently shown better clinical outcomes at lower costs. And Hierarchical Condition Category Coding is the language clinicians use to document the diagnoses of chronic conditions and the complications and various disease states that contribute to risk.
Why should doctors care about HCC coding?
Doctors should, first and foremost, care about patients – and they do. But as a mechanism of that care, doctors must diagnose with specificity and document with accuracy in order to provide care and the revenue that affords that care. And HCC coding is how that is done. HCC coding is the documentation foundation for most of the value-based care arrangements used today. With “value-based care” usually being equated with Medicare Advantage, in coming years we believe that VBC will be incorporated into nearly all types of financial models.
HCC coding falls under the broader term of Risk Adjustment (RA) models for prospective payment. These models are designed to determine risk scores and assign a fee according to the patient’s level of risk.
In the Medicare Advantage world, these models use certain demographic and HCC codes to assign a risk score to patients known as an RAF. The assumption is the sicker the patient, the higher the RAF, the more dollars it will take to care for this patient during any given year. Therefore the RAF score of any patient population will determine the prospective payment Medicare disburses.
This prospective payment model based on RAF does 2 things:
- Aligns physician incentives. Currently, clinicians make money from taking care of sick patients. The sicker the patient, the more visits, tests, surgeries they have to do, and the more they are reimbursed. In this model, clinicians are incentivized to keep patients healthy and therefore require LESS tests and surgeries.
- Spurs clinical innovation the right way. Right now, pharmaceuticals and medical hardware companies are all trying to find ways to treat diseases. The newer the drug or medical device, the more revenue they make. In this model, healthcare groups are incentivized to find new ways of preventing the disease progression from ever needing the latest drug or newest medical surgery equipment.
How can DoctusTech Help?
We provide a modern learning tool for the modern clinician, using gamification, competition, real prizes and administrative oversight to see who is engaging and who needs a little extra help. Also, our app deploys all the subtle nudges and complete with the most advanced HCC code search tool on earth.
DoctusTech helps clinicians learn HCC coding through clinical vignettes in an app that is fun and engaging. Diagnosing with the appropriate HCC code is a critical skill for modern clinicians who care for patients in a value-based care arrangement.
You cannot treat what you do not accurately diagnose, and you cannot afford to treat what you do not appropriately code. Without the correct diagnoses and accurate documentation and coding, caring for patients with complex disease will be unsuccessful, leading to increased avoidable hospitalizations and increased cost to the organization.