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How VBC delivers on the quadruple aim

When we talk about optimizing health system performance in the value-based care (VBC) model, it’s common to refer to the quadruple aim: improved patient outcomes, improved patient experiences, improved provider experiences, and reduced costs. And the best way to determine whether or not the VBC model is delivering on these aims is to talk to those who work on the frontlines. So, we asked some VBC thought leaders to share their experiences of how the value-based care model delivers on the promise of the quadruple aim.

 

Improved provider experiences

A decade ago, a paper published in the Annals of Family Medicine by Thomas Bodenheimer, MD and Christine Sinsky, MD, recommended that the long-established triple aim be expanded to include “the goal of improving the work life of health care providers, including clinicians and staff.” At a time when clinician burnout levels sit at around 63%, this latest aim feels more important than ever.

 

Dr. Gabriel Waterman of SCAN Health Plan explains how he sees the difference between working in a traditional fee-for-service model versus a value-based one, in terms of the provider experience:

 

“The reason I don’t work in fee-for-service is because I didn’t want to be measured by how many RVUs (relative value units) I had produced, or how many patients I’d seen that day. I knew that wouldn’t feel meaningful – and many clinicians who work in that sort of environment don’t even have access to outcomes data.”

 

“In value-based care, it’s all about the outcomes – and that’s just so much more rewarding for me as a clinician.”

– Dr. Waterman, SCAN Health Plan

 

Better patient experiences

When the success of a health system is no longer measured by patient volumes, it creates space and frees up resources to dedicate to improved patient care. Dr. Rayny Ramirez of Community Medical Group tells us of just such an experience:

 

“I remember visiting another clinic, and I saw this senior walking in. No shoes, poorly dressed… just in a bad way. One of the medical assistants showed up, and returned 10 minutes later with shoes, clothes, food…. She just went and bought it with the funds available based on how the company operated. They even arranged for the person to sleep at a hotel for the next couple of nights.”

 

“These are things you cannot even imagine in fee-for-service.”

– Dr. Rayny Ramirez, Community Medical Group

 

Lower costs

Value-based care organizations won’t necessarily prioritize lower costs if they come at the expense of true ‘value’, expressed by the equation: 

 

As Dr. Ramirez explains: “It’s all relative to how you measure the value of VBC. In my previous stewardship, we were able to improve or extend life by an average of five years in seniors with a certain number of conditions. Potentially the costs are higher, but what’s the cost of living five more years?”

 

But in many cases, cost and quality DO go hand-in-hand. Dr. Waterman picks up the baton, explaining how Medicare hospital-at-home programs can help to reduce costs and improve both the provider and patient experiences:

 

“Even if it costs $1,000 to send a clinician to the home, do remote telemetry, and give them IV antibiotics, it’s still a lot cheaper than providing that care in the hospital… Again, as a clinician, it’s so rewarding if you’re able to say: ‘you really need IV antibiotics, but we can do this at home instead of in the hospital’.” 

 

“That improves the patient experience and offers satisfaction as a provider.”

– Dr. Waterman, SCAN Health Plan

 

Better patient outcomes

Finally, the last goal of the quadruple aim is arguably the most important – and to many, where the success of value-based care will be judged. It’s also where some of the most incredible, impactful stories can be found. Inspira Health’s Krystyna Sienkiewicz shares an experience from her early days with the Inspira team:

 

“We had probably three people on the team, and we were doing things like transitional care management – so calling patients after they were discharged from an inpatient stay to get them to follow up with their PCP. We also covered some preventive metrics during those calls, and identified several patients that had not had their colorectal cancer screening. It was flagged for our nurses, they went over it, and they convinced the patients to do a fecal occult blood test – something they could do in the privacy of their own homes.”

 

“There were three patients who were identified with colorectal cancer, and they had no idea that they even had it. They were able to get the treatment that they needed and are now cancer-free.”

 

“That was a direct result of what we were doing from a value-based care perspective.”

– Krystyna Sienkiewicz, Inspira Health

 

In conclusion:

Value-based care organizations like those represented by our three experts strive every day to deliver on the four tenets of the quadruple aim. But the documentation complexity inherent in the CMS risk-adjustment model can create additional challenges for providers. Fortunately, DoctusTech’s HCC training app provides an easier way for clinicians to learn the intricacies of HCC coding – offering up to 90% engagement and 75% knowledge retention. And at the point of care, our integrated platform works seamlessly with 70+ major EMRs to help clinicians raise chronic HCC recapture rates up to 92%.

 

If you’d like to make it improve documentation accuracy and make it easier for your clinicians to deliver exceptional patient care in the VBC model, book a demo with DoctusTech today.

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Why does accurate HCC coding matter?

Clinicians and other medical staff find it hard to care about HCC coding. Here’s why they should.

Selling clinicians on the value-based care (VBC) model should be straightforward. In theory, it promises more time with patients per encounter – with a greater focus on patient outcomes when compared with the ‘numbers game’ of fee-for-service medicine. For many, VBC captures why they became doctors in the first place. But for some, the documentation requirements associated with the value-based care model stand in the way.

 

“The documentation is intimidating,” agrees the Chief Clinical Officer of a leading at-risk physician group. “And it wasn’t something that providers learned in medical school.” The ‘intimidating documentation’ around HCC coding is highly off-putting to providers. They don’t care about it, they don’t want to learn it, and they’d rather be spending time with patients. So why does accurate HCC coding matter, and how can we make clinicians care about it?

 

The problem

 

Physician burnout remains a major issue, and it’s clear that the accumulation of non-clinical tasks is a significant contributing factor. As an example, a recent study from the American Journal of Medicine reports that primary care physicians spend an average of two hours interacting with an EMR for every hour of patient contact – that’s 4.5 hours each day in the clinic, with an additional 90 minutes at home every evening. This quote from the same report puts the problem into context:

 

“I am no longer a physician but the data manager, data entry clerk and steno girl… I became a doctor to take care of patients. I have become the typist.”
American Journal of Medicine

 

With physician burnout rates reportedly as high as 63%, it’s hardly surprising such attitudes persist. In the value-based care model, learning the intricacies of risk adjustment and maintaining accurate documentation represents another time-consuming task for clinicians. That’s why it’s so crucial that they understand and appreciate the value of accurate HCC coding.

 

Accurate HCC coding and reimbursement

 

“In addition to helping predict healthcare resource utilization, RAF scores are used to risk-adjust quality and cost metrics. By accounting for differences in patient complexity, quality and cost performance can be more appropriately measured.”
– American Academy of Family Physicians

 

The first and most obvious point to make here is that accurate HCC coding has a direct influence on reimbursement. The risk-adjustment model depends on all risk-adjusting conditions being coded accurately – ensuring each patient has a risk score that suitably reflects their likely cost of care. Therefore, accurate coding ensures that healthcare services are appropriately reimbursed for the level of care provided to patients. In a nutshell, clinicians and other medical staff should care about accurate HCC coding because it ensures they get paid.

 

Inaccurate coding, meanwhile, can lead to under- or overpayment – either of which can be highly damaging to an organization’s financial stability.

 

Accurate HCC coding and compliance

 

While HCC compliance regulations can seem vague or confusing, the most common causes of audit failure include the following:

  1. Under-documented chronic conditions
  2. Incorrectly-recaptured acute codes
  3. Incorrect initial encounter codes
  4. Exclusion codes coded together
  5. Inclusion codes missed

Accurate HCC coding, therefore, is a matter of regulatory necessity if organizations are to avoid penalties and other legal repercussions. While compliance isn’t necessarily the most powerful motivator for reluctant clinicians, it is an important reminder that accurate HCC documentation is non-negotiable for VBC organizations.

 

Accurate HCC coding and patient care

 

“Accurate diagnosis coding can help your team identify high-risk patients and give them the right care at the right time.”
– American Academy of Family Physicians

 

This final point is likely the one that will resonate most powerfully with clinicians and other clinic and hospital staff. At its heart, the value-based care system is about reducing costs and increasing the quality of patient care.

 

As a part of that, accurate HCC coding helps:

 

  • Identify patients at greater risk of certain conditions or complications
  • Implement preventative screenings and lifestyle interventions
  • Minimize hospitalizations and readmissions
  • Ensure patients have access to the appropriate resources for their needs
  • Improve patient understanding and management of chronic conditions
  • Improve care coordination
  • Ensure all relevant providers have access to accurate, up-to-date information on patients’ health status
  • Improve quality reporting and identify areas for improvement

Accurate HCC coding is an unglamorous but essential aspect of value-based reimbursement – helping to support the fundamental promise of value-based care to improve patient experiences and enhance patient outcomes.

 

Improving engagement, getting buy-in

 

“Physician engagement can make or break a hospital’s HCC-capture strategy.”
HFMA

 

It’s clear that accurate HCC coding is vital to the success of accountable care organizations and other VBC providers. But to code accurately, clinicians and other staff must first undergo HCC coding education. The trouble is, traditional methods of HCC training no longer work. Knowledge retention rates for ‘tired and tested’ techniques such as lectures, written materials, and demonstrations range from between 5% and 30% – which is to say nothing of the critical matter of clinician engagement.

 

 

Here at DoctusTech, we employ a revolutionary app-based learning method using a mix of multiple-choice questions and clinical vignettes. This active learning approach generates knowledge retention rates as high as 75%, and better yet, clinicians love it. Our research shows that the DoctusTech app is the preferred method of HCC education for 9 out of 10 clinicians, with an engagement rate of 90%.

 

If you’re struggling to get your clinical staff to care about accurate HCC coding, it’s time you tried the DoctusTech app. Schedule a demo today.

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Exploring blended payments

We asked VBC thought leaders to share their experiences of fee-for-service and value-based reimbursement models. 

 

While value-based payment models are on the rise in the U.S, primary care practices still receive the majority of their payments via fee-for service. In 2022, 70% of primary care physicians reported receiving fee-for-service payments, versus just 46% for value-based payments. Although many health systems are now transitioning to the value-based care model, this transition can’t happen overnight – meaning some combination of both value-based and fee-for-service models is inevitable. In this article, we’re going to explore so-called blended payments in value-based care, and ask whether organizations should persist with them long-term.

 

Are value-based care and fee-for-service incompatible?

 

Value-based care and fee-for-service are often considered to be polar opposite reimbursement models. While the fee-for-service model sees providers receive payment for each service they deliver – regardless of the quality of care or patient outcomes – value-based medicine follows the equation of ‘value = quality ÷ cost’.  That means, under the VBC reimbursement model, providers are rewarded for delivering high-quality care and positive patient outcomes – while effectively managing costs. 

 

In the highly-politicized U.S healthcare landscape, it’s possible to see value-based care and fee-for-service medicine as philosophically incompatible. “The difference is the basic premise of having a transactional relationship with a healthcare provider, versus putting the responsibility of the outcome of that relationship on the healthcare provider,” says Dr. Rayny Ramirez, CEO, Community Medical Group. “At the clinical level, doctors can care less about financials and cost. Doctors just want to be doctors.”

 

Blended payment: a marriage of inconvenience

 

The transition to value-based healthcare slowed during the turmoil imposed by the COVID-19 pandemic, but this was never a rapid process to begin with. Medical Economics describes how the industry has “inched toward” value-based healthcare over the last decade “on an incremental basis”. This slow shift has left many organizations in a kind of limbo, forced to operate blended payment models comprising both value-based and fee-for-service payments. Although a marriage of convenience, these blended payment models could potentially explain recent criticism of VBC success rates, says the Chief Clinical Officer of a leading at-risk physician group who prefers to remain anonymous.

 

“I wonder if they’re trying to do both,” she tells us. “I wonder if they’re trying to do this treadmill of fee-for-service and – ‘oh yeah, I have to slow down to see my VBC patient’. It’s impossible.”

 

“I always equate it [blended payment] to a cross-training sneaker: it’s not good for running, it’s not good for playing tennis. If you want to run, you wear a running shoe, and if you want to play tennis, you wear a tennis shoe.”

 

Both of our experts have experienced the blended payment method first hand, and both have questions about its efficacy as a long-term solution. 

 

“I’ve been in an organization that’s fee-for-service, I’ve been in an organization that is value-based, and I’ve been in an organization that is both at the same time – or trying to be both at the same time – which is kind of crazy,” says Dr. Ramirez. 

 

“It is really hard to do both well,” the CCO agrees. “And I think that’s why some providers don’t necessarily see the value in value-based care – because they just see the documentation requirements and preventative care checklists, and say ‘this is harder medicine’. They’re not looking at the outcomes.”

 

Reaping the benefits

 

Both of our interviewees extol the virtues of working for dedicated value-based care organizations over the blended model. “I love our health center because we’re just a running shoe!” the CCO laughs. “I think certain providers say their VBC programs haven’t been successful because they’re living with one foot in each world.”

 

Dr. Ramirez agrees. “It’s all relative to how you measure the value of VBC,” he tells us. “In my previous stewardship – with a different organization that provided care for senior patients – we were able to improve or extend life by an average five years in seniors with a certain number of conditions. Potentially the costs are higher, but what’s the price of living five more years?”

 

Both parties are realistic regarding the challenge of transitioning to value-based care. “I’m not going to pretend that there aren’t more rigorous documentation requirements in value-based care,” the CCO says. “The documentation is intimidating. And it wasn’t something that providers learned in medical school… If you’re used to commercial documentation, you might be like, ‘this is a burden’.”

 

Accurate documentation starts with education. Clinicians, MAs, coders and other staff must buy into the increased burden of documentation necessitated by the switch to value-based care, before learning the many intricacies of risk adjustment and HCC coding. The DoctusTech HCC coding education app applies active learning theory to engage clinicians at 90%, and encourage lasting behavior change with 75% knowledge retention. It’s the preferred method of HCC education for 9/10 clinicians – ensuring users not only retain the valuable information they’re taught, but that they’re motivated to keep learning for the long term. 

 

If you need help managing the transition to value-based care, get in touch and arrange a demo of the DoctusTech app today.

 

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Risk, Revenue & Care: How HCC coding and RAF impact Value-Based Care Revenue and Patient Outcomes

The basics of RAF and how it is calculated.

Total HCCs for a single patient equal RAF score

 

Every VBC patient has a Risk Adjustment Factor (RAF) score, and the score follows the patient. The more medically complex diagnoses render a higher RAF score. The higher the score, the more resources required to care for that patient; therefore, Medicare pays more to care for that patient. No matter where the diagnoses and HCC codes originate, RAF scores follow the patient back to the group that has taken on risk for that patient. So if your patient sees a cardiologist and is diagnosed with afib, that will impact your capitated reimbursement from CMS. And that will also impact the care required to keep that patient healthy and out of avoidable hospitalizations.

 

Although there are 80+ HCC codes, Medicare has created 8 special groups of HCCs with similar diagnoses of differing severity: cancer, diabetes, COPD, renal disease, substance use disorder, cardiorespiratory failure, psychiatric disorders and pressure ulcers. HCC codes that belong to one of these groups may be overridden by a different HCC in the same group higher up the hierarchy.

 

For example HCCs 8-12 all involve cancer, from solid breast tumors to leukemia. If a patient has a cancer in HCC 8 and a cancer from HCC 11, the more serious category (HCC 8) will be the only one that is reimbursed. Also worth noting, lower numbered HCCs trump higher numbers in their group, and have a greater impact on RAF scores.

 

Medical complexity diagnosed & documented determines Reimbursement

CMS uses RAF scores to render capitated payments

 

As illustrated above, HCCs contribute to RAF through a somewhat complex relationship, but the key is accurate documentation of all patient conditions and treating the patient for the complexity that has been diagnosed. Each patient has a RAF score that typically falls within the range of 0.6 to 1.2. When looking at a risk contract, CMS reimburses for each patient according to their RAF score, adjusted for age, sex and regionally based on costs of care.

 

So the overall average RAF within a contract determines the overall reimbursement for that population. The payments are termed capitated (from the Latin word for head) as it is paid “per head” rather than per-action, or CPT codes submitted in a FFS arrangement. Often, revenue is looked at in a per-member per-month average (PMPM), where the total population RAF and the total PMPM capitated payments are reviewed to determine how well a contract aligns with regional averages, numbers per clinic, or per doctor’s panel.

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Value-Based Care Revenue and Outcomes: Impact of HCC Coding and RAF

Diagnosing for risk in VBC is the unsung hero fixing healthcare behind the scenes. In this blog, we dig into diagnosing for medical complexity & documenting with ICD-10 codes. 

 

Diagnosing for medical complexity

Physician diagnoses patients with all medical conditions.

 

One shift when transitioning to Value-Based Care is the need to diagnose very specifically for complexity, rather than simply diagnosing a disease. In the old Fee-For-Service (FFS) model, it would be reasonable to diagnose simply diabetes mellitus. In a VBC model, it would serve the patient better to diagnose with a high degree of specificity—type 2 diabetes mellitus with neuropathy—to fully capture the complexity and severity of the disease, ensuring that all conditions are documented and the plan of care is executed accordingly. 

 

“Medical complexity” is another way to say “How hard is it going to be to keep this patient out of the hospital?”

 

For patients with very mild chronic conditions, it is often easier to manage their symptoms, keep them on their meds, and keep them healthy; thus, not requiring intensive medical resources. Comparatively, patients with very complex diseases can be very resource-intensive, and require a great deal of time, attention, services, and oversight to manage their chronic conditions and maintain their health. Therefore, these patients with more complex disease states are reimbursed at a higher rate, to allow for more intense and expensive care.

 

 

Documenting with ICD-10 Codes

Diagnoses are documented with the appropriate ICD-10 codes

 

ICD-10 codes are still the backbone of medical diagnoses, and typically the only codes used in a VBC arrangement. So the diagnosis coding that was learned in FFS arrangements is still at play, just with a slightly different focus – especially, when diagnosing chronic conditions.

 

Hierarchical Condition Categories are a subset of ICD-10 codes, therefore not all ICD-10 codes map to HCC codes. Each risk-adjusting diagnosis will alter the patient’s risk profile, with the more serious conditions increasing RAF score more than less serious. But some HCCs supersede others when they are within the same category. For example, E11.9 – diabetes without complication will add 0.11 to the patient’s risk score, but E11.22 – diabetes with chronic kidney disease will add 0.33. As the codes are hierarchical by category, the highest diabetes score will be the one passed along to the patient’s total RAF – not both. 

 

Risk follows the patient, not the provider

The risk score of a patient is tied to the patient themselves, not the provider. Diagnoses submitted to medicare by any clinician anywhere will add to the patient’s risk profile. Each patient has just one PCP assigned to them when they join a managed care plan, and that PCP will receive payment for that patient’s care, as they are the one taking on risk. 

 

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How HCC coding and RAF impact Value-Based Care Revenue

The relationship between medical complexity, documentation, risk, innovation, and revenue is actually far more simple than it sounds.

 

We are often asked very broad questions about how all of the moving pieces of VBC work together. How does highly specific and accurate diagnosing with HCC codes relate to patient care? Do HCC codes help patients, or is coding just to generate revenue? How do you avoid under-coding, or over-coding, and harden your charts for an audit? What is the role of the clinician, when there are also coders? How do you educate clinicians on HCC coding, when they barely engage in the seminars? How should clinicians view HCC coding and RAF scores as a component of patient care? 

 

There are a lot of questions. So in this series of blogs, we are going to lay out a robust and thorough explanation of each piece of the VBC puzzle, share how they relate and impact each other, and by the end, you will have a thorough understanding of both the VBC space and your role in it. 

 

First, a word about risk. Upside risk, downside risk, two-sided risk, quality scores, stars… there are only really a few things you need to know about risk.

In Value-Based Care, when you take on risk for a patient population you are making a wager. 

 

Your organization wagers that they can both run a business and keep a patient population healthy for a predetermined dollar amount, set by CMS. If you are caring for a very sick patient population, you will need more resources. And the wager is that your organization can provide effective care within the budget. This incentivizes a care team to keep patients healthy, rather than only treating them when they get very sick. 

 

The organization that takes on risk is reimbursed in a capitated payment model, paid per-member, per-month (PMPM), based on the Risk Adjustment Factor (RAF) of your patient population the year before. That score is the sum of all RAF scores from the patients in your VBC contract. The RAF score of each patient is the sum of all the diagnosed chronic conditions, documented with Hierarchical Condition Category codes (HCC codes) that risk adjust. CMS payment models typically pay for conditions diagnosed the previous year.

 

Over the next few weeks, we are going to dig deeper into four central concepts in Value-Based Care, with special attention paid to how each piece impacts patient care. 

 

– Diagnosing for risk in VBC

– The basics of RAF and how it is calculated. 

– How RAF and Revenue drive Patient Care and Innovation

– RAF, Revenue, Audits and the DOJ

 

To our VBC clinicians, thank you for the work you’re doing to move patient outcomes to the forefront of healthcare. Thank you for truly caring for your patients – and for your patients with all the required learning, coding and documentation. It matters, you matter, and your healthy patients will thank you.

 

To our VBC admins, operators and physician executives, your management of all the moving parts and pieces is critical to achieving the pivotal shift from fee-for service to a value-based model. Thank you for your commitment to patient-centric care and clinician satisfaction. Without you at the helm, the system would never change. 

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VBC Industry Insights From HCP-LAN’s Annual Report

Values-based healthcare reimbursement has been adopted more quickly in some healthcare sectors than in others.

 

According to the LAN’s latest APM Measurement report, 40.9% of US healthcare payments—representing over 238 million Americans and more than 80% of the covered population—were generated through value-based reimbursement programs last year. Population-based payments and downside risk agreements were included in these programs, in addition to upside risk agreements.

 

In addition, almost one fifth (19.8%) of all healthcare payments made last year were in some way tied to value or quality of care while still being based in fee-for-service. The remaining 39.3% of payments were strictly fee-for-service.

 

Despite the fact that the healthcare industry has adopted value-based reimbursement, adoption is often glacially slow. But values-based reimbursement has been adopted quicker in some segments of the healthcare system.

 

Where progress is occurring.

According to the APM Measurement report, Medicare and Medicare Advantage are leading the charge in value-based reimbursement – no surprise there.

 

Just 15.0% of traditional Medicare payments and 38.0% of Medicare Advantage payments were fee-for-service in 2020, down from 2019 data showing 14.1% of traditional Medicare payments and 46.0% of Medicare Advantage payments being fee-for-service.

 

In both programs, the proportion of value-based reimbursement in two-sided risk alternative payment models continue to increase year over year. In traditional Medicare, 24.2% of payments were part of some two-sided risk model, compared to 20.2% in 2019. In Medicare Advantage, the percentage of payments in two-sided risk models increased from 28.6% in 2019 to 29.3% in 2020.

 

Insight: Medicare Full Risk grew by 20% between 2019 and 2020.

Medicare Advantage Full Risk grew only 3% in the same period.

 

Despite fee-for-service payments making up 59.0% of Medicaid payments in 2019, value-based reimbursement adoption increased from 10.6% to 14.5% in 2020.

 

Insight: Value-Based Reimbursement adoption grew 36% 2019-2020

 

According to the report, private payers covered 62% of the lives represented in the LAN’s data, but only 10.8% of payments made in 2020 were from two-sided risk models, while over half (51.5%) were from fee-for-service.

 

In addition, a higher proportion of payments to providers from private payers (11.1%) in 2019 was tied to two-sided risk models. Furthermore, 53.5% of payments were fee-for-service, as shown in the report.

 

 

How to accelerate value-based payment and risk

Industry experts at the 2021 LAN Summit concur that a lag in value-based reimbursement adoption is shown by the results of the 2020 APM Measurement report. However, there is speculation that risk-based models will be adopted more rapidly over the next few years.

 

According to the report, 87% of respondents believe that alternative payment model activity will increase; none of them believe it will decrease. In addition, the majority agreed that adoption would lead to higher quality, more accessible care, as well as improved care coordination.

 

Despite the payors’ perspectives, provider willingness to take financial liability, their capability to implement models, and their interest and willingness are still the greatest barriers to value-based payment adoption.

 

An “exponential” increase in the level of cooperation between payers and providers has occurred, and more providers are bringing to us the idea of entering into risk arrangements, Shrank said. Because of the outbreak, he thinks more people will be open to working in risk arrangements.

 

However, payers still must offer the right incentives to incentivize providers to participate in value-based reimbursement and eventual downside risk.

 

Keeping the momentum going with value-based reimbursement and risk adoption in healthcare requires leadership, buy-in, and aligned incentives.

https://hcp-lan.org/apm-measurement-effort/2022-apm/

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How Hospitals Can Tackle Surges With Value-Based Care

With the flu season ramping at unprecedented rates, and a new surge of RSV coming when COVID-19 numbers are rising again, the topic of a healthcare surge emergency is back in the headlines. What the New York Times is calling a “Tripledemic” is threatening to overwhelm providers and hospitals yet again. During the peak of the pandemic, hospitals experienced a surge in demand for physical resources and personnel that lasted nearly two years.  And just when things started to adjust back to some recognizable norms, the question is again on everyone’s mind: “How do we tackle a surge?”

 

According to Shereef Elnahal, MD, president and CEO of University Hospital and former Commissioner of New Jersey’s Department of Health, hospitals and health systems often lose money during their peak seasons. Supply shortages are largely due to the fact that most hospitals use a fee-for-service payment model.

 

Hospitals that charge on a fee-for-service basis are paid based on the volume of patients they treat, not the quality of patient outcomes. Because of this, hospitals usually operate at full capacity in order to reap the greatest rewards. When patient volumes rise during peak seasons, however, hospitals have little margin for error.

 

According to static payment rates for inpatient care, hospitals may struggle with seasonal demand. In order to keep up with surges, health systems may have to hire more staff or order more supplies, which leads to increased expenses despite no increase in revenue.

 

During flu season, primary care physicians often augment their workforce by up to 30 percent and still face financial challenges and capacity limitations. Across all healthcare facilities, staffing shortages have become worse as a result of the COVID-19 pandemic, which increased the need for healthcare professionals.

 

Rather than relying on simply adding more headcount, health systems needa model that can easily adjust healthcare delivery to fit any situation, including increased patient capacity and pandemic surges. Creating a value-based payment model may give health systems more flexibility when dealing with demand surges.

 

According to the quality of care, providers are compensated using value-based payment models, not the quantity. This approach may inspire health systems to improve staffing procedures. In contrast to dividing physicians’ time in a way that will lead to the highest number of completed services, health systems might focus on patient needs and health outcomes in order to address them.

 

Physicians using a value-based model are less likely to refer patients to specialty care facilities if those referrals are not medically beneficial.

Because of Maryland’s value-based all-payer model, which reimburses hospitals using global budgets for inpatient episodes of care, hospitals in the state were able to manage the influx of patients during the pandemic far better than neighboring states with different models.

 

A study from JAMA Network Open noted that the all-payer model also decreased surgical spending and surgical complications. Providers can save resources and supplies for busy periods if they are reimbursed based on outcomes rather than quantity of services.

 

Patients may be able to avoid expensive hospital stays, saving staff time and resources, if they have access to healthcare services at home. Hospitalization rates may also be lowered by using home-based primary care services.

 

In addition, health systems could leverage telehealth services to assess patients and determine if an in-person visit is required. According to the authors, telehealth use could improve access to care and save hospitals money.

 

Patients may also be able to manage their acute conditions from home using remote patient monitoring technology.

 

Surges can also be a contributing factor to physician burnout. That is why reducing physician workload (blog post) should be a part of hospitals’ strategy of dealing with patient surges.

 

The DoctusTech Mobile App is based on our successful HCC education and retention strategy, which relies on clinical vignettes customized to the clinicians’ weaknesses and strengths, which are sent to their mobile phones every week. With an engagement rate of 90%, DoctusTech App results far exceed any other learning tool, technology, or strategy.

 

After using the app for HCC coding education, clinician RAF accuracy is consistently increased based on the learning data.

 

What methods does the app use to accomplish this?

 

Our app gamifies the learning experience, connects clinicians with one another, allows them to compete for real prizes, and provides administrative support. In addition, the most advanced HCC code search tool in the world is available. Clinicians earn 25 CME hours every year as they learn HCC coding in a non-boring app!

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DoctusTech Helps: Change Clinician Behaviour

According to the American Journal of Managed Care (AJMC), the least effective method for continuing medical education (CME) for clinicians is distributing printed materials: emails, PDFs, flyers, email blasts, and so on. Many medical professionals believe that clinician education should be concerned with encouraging continuous development rather than simply raising consciousness. What, then, are the most effective strategies for accomplishing the goal of both informing and changing clinician behavior?

 

The AJMC says that the methods of intervention most commonly deployed in teaching doctors HCC coding are those same methods determined to rarely create lasting change in physician behavior (classroom lectures, emails, PDFs, flyers, email blasts). So most frequently utilized modes of learning are clearly out.

 

“When you’re seeing patients, you remember the questions, and you remember what you need to ask the patients.” – Dr.  Villaplana-Canals, Florida, DoctusTech App User

 

Both the AJMC and common sense agree  that active education methods and multifaceted interventions are the most effective when it comes to educating and changing physician behavior. The DoctusTech mobile app provides active education and multifaceted interventions through clinical vignettes. In other words, our app helps you achieve your desired outcomes – as a physician, or as an operator for your physicians. In fact, we provide the most effective intervention methods, demonstrated by consistently better outcomes.

 

How?

 

Learning in the app is driven by clinical vignettes, placing clinicians in a real-life patient scenario, presented with symptoms and facts, and then asked questions about diagnosis and documentation, all in an effort to alter the method of diagnosing from the fee-for-service approach most physicians were educated in to a value-based care system, in which chronic conditions are diagnosed in a very specific manner, with an eye to risk and outcomes. By including any and all information about the diagnosis that impacts risk adjustment in the diagnosis, clinicians learn to both diagnose and document those diagnoses with supporting information in the chart.

 

“The mobile app is wonderful, in that it’s a clinical vignette – it’s what is literally in front of their face, and it gets them thinking.” – Teresa, Director of Clinical Documentation Improvement

 

For clinicians, behavior change is accomplished through learning in clinical vignettes with the DoctusTech mobile app. Doctors learn more deeply and permanently about diagnostic procedures and proper documentation by sitting through a clinical vignette. The socratic method is a highly regarded teaching tool as well as being one of the most commonly used teaching strategies in medical school. The socratic approach is utilised by medical students as they learn by questioning in clinical vignettes. It is fitting, therefore, that they will gain a new store of knowledge through clinical vignettes.

 

“It does reinforce for us something that, although most doctors use a problem list, most of the problem lists … ended up being too long, too nonspecific, and very unwieldy to use in the clinic. The training taught me to make sure you have the linkages and causations clearly laid out.” – Dr Joseph Bateman, Medical Director, Christ Hospital, DoctusTech App User

 

Clinicians can justify the RAF score impact of those diagnoses by supporting them with appropriate documentation that meets the MEET criteria. When there is an audit (When, not If), their charts are proper and in order, and their patients are well cared for.

 

Rather than diagnosing “diabetes” a DoctusTech educated physician would instead test for complications and diagnose a specific disease condition, accurately reflecting the capitated payments for that person’s care. The behaviour change comes from switching from one ICD-10 code that doesn’t risk adjust to a more specific diagnosis, using a different ICD-10 code that does adjust the risk of that patient and accurately reflects the change in capitated payments for their care.

 

Book a demo today, and experience DoctusTech Mobile App’s transformative teaching techniques for yourself!

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DoctusTech Helps Value Based Care

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:

  1. 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.
  2. 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.

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DoctusTech Helps: Increase RAF Accuracy

“I don’t care if the RAF goes up or down, I only care if it’s accurate.”

Dr. Farshid Kazi, Co-Founder, DoctusTech

 

If an organization is caught over-coding, up-coing, diagnosing conditions that either do not exist or are not supported in the chart, the cost of these errors can be very high. Audits are no longer just for health plans, provider groups like Sutter, Kaiser (and many others) have also been audited by the DOJ and hit with heavy fines.

 

On the other side of the board are many plans and provider groups that are struggling to diagnose and accurately document chronic conditions that truly do exist and risk adjust, leading to poor performance in VBC contracts and clinician burn-out. 

 

RAF accuracy is achieved through a perfect balance of accurate diagnosis and accurate documentation. 

What is Risk Adjustment Factor Scoring

Risk adjustment factors are used to estimate the expected outcome for a patient based on a number of different factors. One important factor is the patient’s age; other factors include socioeconomic status and comorbidities such as chronic illnesses or conditions. Each of these can be scored to give a single risk adjustment factor score. 

 

DoctusTech Enables 30% Rise in RAF Accuracy

How?

We teach clinicians how to think about chronic conditions, improve diagnosis at the point of care, and help documentation and HCC coding – all in a lovable mobile app. And not only do clinicians learn how and what to code, the app is also the most powerful HCC code finder in the palm of your hand. Look up the code through a variety of intuitive queries, by tests that might indicate a diagnosis, and by related conditions – complete with complexities and branch-points to help drill down into greater specificity. 

 

While we cannot share sensitive client data, we can confidently state that a 30% increase in RAF accuracy is well within the normal range for our clients. 

 

DoctusTech Helps by Boosting Clinician Knowledge and Changing Behavior Just by Engaging With a Lovable Mobile App

The app uses the classic learning technique we all grew to know and love in med school: the Socratic method. By posing questions within a clinical vignette, clinicians learn—and remember—how to diagnose, code and document for risk adjustment. By increasing the fund of knowledge around diagnosing chronic conditions, the app improves unique code capture and documentation, boosting RAF accuracy over a very short period of time. After the initial self-assessment, clinicians are only asked to spend about five minutes per week engaged on the app, and behavior change outpaces traditional HCC teaching techniques by a significant margin. 

 

 

DoctusTech HCC Integrated Platform

 

Instead of clinicians having to go to various external data sources to gather information, DoctusTech’s HCC integrated platform, HCC 360, consolidates all data sources and presents them to clinicians while they are writing progress notes. Here’s how you can achieve greater RAF accuracy with DoctusTech:

 

Improve Patient Visits: Based on your patient’s chart, get real-time prompts for questions to ask or labs to consider.

 

Automate Chart Review: Translate your patient’s chart into HCC code using our A.I. in seconds, based on evidence-based medicine.

 

Faster Progress Notes: You won’t have to wade through third party portals or paper suspect codes anymore; we bring all sources into your EMR to simplify your life.

 

As healthcare continues to evolve, it is crucial that providers get educated and improve their skills in using HCC codes. DoctusTech is a revolutionary new way to improve the accuracy of HCC coding by making sure you know exactly how to code each condition. Our simple mobile app that engages clinicians in an easy guided learning experience while they file HCC coding notes. After only five minutes of training, clinicians can quickly and accurately code their own charts and boost the accuracy of their efforts.

 

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Amazon Announces Plans to Buy OneMedical

Amazon has announced plans to buy OneMedical for $3B. OneMedical is a brick and mortar plus digital healthcare marketplace that operates in several major U.S. markets. The acquisition is Amazon’s latest move in the healthcare sector, and analysts say it could be a sign of bigger things to come. This is not Amazon’s first foray into the healthcare market, but after the Haven experiment closed down, the company has kept a relatively low profile while it tests new business models. In June, Amazon was among several investors that participated in a $35 million funding round for Zscaler, an Austin-based cybersecurity firm that offers an edge security service for cloud networks and internet-facing applications and services. A few months earlier in March, news broke that Amazon had hired former pharmaceutical executive Bernard Jegou as its new vice president of e-commerce strategy and new business development. 

 

And in a very public failure back in 2017, Amazon partnered with Berkshire Hathaway and JPMorgan Chase to form an independent healthcare company called Haven, which it quietly scuttled mid-pandemic, February, 2021. Read on to learn more about how this acquisition could indicate continued interest from Amazon in the healthcare space — or if it is just another pivot from one of its many subsidiaries.

 

 

What is OneMedical?

OneMedical is a primary care practice and digital healthcare marketplace that uses technology to reduce healthcare costs and increase convenience for patients. The company has built a network of more than 500,000 doctors and has partnered with health insurance providers across the country to serve more than 3 million members. OneMedical offers a range of services, including access to an online portal for patients and a concierge service for their members. OneMedical’s network of doctors comes from a variety of specialties, including general practice, pediatrics, OB/GYN, and family medicine. OneMedical also offers telemedicine services, including video visits with doctor consultations and prescription refills.

 

 

Why might Amazon be buying OneMedical?

While Amazon has not released any details about why it is acquiring OneMedical, analysts say this acquisition may be a sign that the company has larger ambitions in the healthcare sector. Amazon has a track record of acquiring companies in sectors where it sees potential for disruption and then gradually building out its business there. This could be a way for Amazon to expand its e-commerce business into health insurance. It could also be a sign that Amazon wants to become a one-stop shop for healthcare services. Amazon has been experimenting with new business models in the healthcare space for several years now. The partnership with Berkshire Hathaway and JPMorgan Chase formed an independent health company called Haven began with promise, but was quietly closed a few short years later. And in June, news broke that Amazon had participated in a $35 million funding round for Zscaler, an Austin-based cybersecurity firm whose edge security service could help internet-facing applications and services like those that run on Amazon’s AWS platform.

 

 

Possible reasons for the acquisition

Analysts say there are a few reasons why Amazon might be interested in acquiring OneMedical. Amazon may be looking to expand its reach into healthcare marketplaces beyond its partnership with Berkshire Hathaway and JPMorgan Chase to form an independent health company called Haven. Acquiring OneMedical could give Amazon a foothold in the digital healthcare space, which has been growing rapidly. Amazon could also be interested in OneMedical’s digital platform for its members. Having an online presence and digital tools for patients and doctors could let Amazon expand into other healthcare sectors, including pharmacy. And Amazon might be interested in the data that OneMedical has on its members, which could be useful for the company’s future endeavors in the healthcare space.

 

 

Amazon has bigger plans in healthcare

Analysts say the acquisition of OneMedical could signal Amazon’s intent to become a major player in the healthcare space. It is unclear exactly what the company’s strategy will be, but it is likely that Amazon will focus on improving the customer experience across the healthcare sector. Amazon is no stranger to industries with high-barrier-to-entry business models. The company has made inroads in industries such as grocery and e-commerce, as well as more traditional businesses such as manufacturing and cloud computing. Amazon has long been a disruptive force in the retail sector. The company has reshaped consumer expectations of online shopping and shifted the entire retail landscape in its wake. The company’s foray into digital and bricks-and-mortar retail has been a boon for customers, and it has also provided a boost for shareholders: Amazon’s stock is up almost 102% over the past year.

Value-Based Care and Risk Adjustment

Experts say that Amazon’s involvement may help OneMedical’s risk management as the adoption of more value-based care programmes continues. Most of One Medical’s business has traditionally been generated from charging commercially insured patients per-visit fees, but since the acquisition of Iora last year, Medicare patients are now served, and revenue is captured as a result of savings through risk contracts. According to their website, OneMedical serves scores of Medicare Advantage plans, though patient numbers were not readily available. Scaling value-based care is challenging for providers without extensive data experience. Those in primary care, retail health, and telehealth should be concerned, experts say.

 

 

The big question: Is this a pivot or a sign of future intent?

Analysts say Amazon’s acquisition of OneMedical may be a sign that the company is pivoting from its health technology investments, like Zscaler, and looking to establish a more direct presence in the healthcare sector. But it is  also possible that Amazon has more ambitious plans in the healthcare space that the acquisition of OneMedical is only the first step in. Whatever Amazon’s end goal is in the healthcare sector, it seems likely that the company will take a slow and methodical approach to growing its business. After all, Amazon has plenty of experience building new businesses from the ground up, and it has a track record of entering new sectors and disrupting existing players with a more customer-friendly approach.

DoctusTech Helps Clinicians Learn HCC CodingPosted on

DoctusTech Helps Clinicians Learn HCC Coding

DoctusTech Helps Clinicians Learn HCC Coding

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. 

 

And without a tool to get clinicians quickly up to speed on diagnosing for risk at the point of care, coding accurately and documenting correctly, you will be stuck. Stuck in boring seminars that rarely affect lasting behavior change; stuck with missed diagnoses and missed revenue targets; stuck with patients missing out on essential care; stuck with overworked clinicians; stuck. 

 

How do clinicians learn HCC coding?

This is where DoctusTech Helps. 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.

 

And clinicians earn 25 hours of CME per year, while they learn HCC coding in a non-boring app!

 

In SCUBA diving, the diver must add just the right amount of weight to maintain perfect positive buoyancy; too much and you will sink, too little and you will bob on the surface like a cork. Risk adjustment in value-based care has some similarities: a successful VBC program will diagnose and treat just the right conditions. Not over-coding, and not under-diagnosing. 

 

Clinicians learn HCC coding better in clinical vignettes

And doctors coming out of medical school and even residency programs know little to nothing about HCC coding and diagnosing for Risk Adjustment and Value-Based Care. Traditionally, these clinicians sit in seminars getting force-fed codes in an effort to teach them how to accurately diagnose and document with the appropriate HCC codes. Unfortunately, this is not how every other vital piece of medical information was learned, so clinicians struggle to retain the information and utilize it in daily practice. 

 

Medical education is all about the Socratic method, question and answer, clinical vignettes. Doctors learned to learn this way, and they prefer it. Which is why DoctusTech helps doctors learn HCC coding the way they like to learn – from other doctors, in clinical vignettes, on their own time, and in an average of 5 minutes per week.

 

Truly, DoctusTech helps clinicians learn HCC coding. And when clinicians master diagnosing for risk with HCC codes, your whole VBC program improves. 

 

See more ways that DoctusTech Helps:

  • DoctusTech Helps: Increase RAF Accuracy
  • DoctusTech Helps: Decrease clinician workload
  • DoctusTech Helps: Deploy HCC coding education across your org 
  • DoctusTech Helps: Change Clinician Behavior
  • DoctusTech Helps: Value-Based Care
Everything You Need To Know About HCC Coding TrainingPosted on

Everything You Need To Know About HCC Coding Training

Everything You Need To Know About HCC Coding Training

Why is HCC coding training important? Without proper coding, it is impossible to diagnose accurately, treat effectively, document those diagnoses, or achieve revenue goals. Coding training will help you master the skills you need to properly code patient records, so investing in HCC coding training might be the right move for you! Read on to learn more about HCC coding training!

 

What is HCC coding?

Hierarchical condition category (HCC) coding was created to estimate future health care costs for patients. The Centers for Medicare & Medicaid Services (CMS) HCC model was established in 2004 and is increasingly being used as value-based care gains traction. The HCC model relies on ICD-10-CM coding to assign patients risk scores based on their medical condition. Each condition is associated with an ICD-10-CM code. For example, a patient with few serious health problems is likely to have average health care costs for a specific period of time. Patients with many chronic conditions, however, are more likely to have higher health care utilization and costs.

 

Why is HCC coding training so important?

As we mentioned above, proper healthcare coding is important for a number of reasons. However, even the best healthcare providers cannot properly code without the right training. If you are new to the healthcare industry, you will need training to learn the coding system and understand the complexities of accurate diagnosis and documentation. If you have been in the industry for a few years but have not kept up with the latest coding trends, you may also need training to refresh your skills. Whatever your situation, it is important to take the time to invest in HCC coding training. This training will help you master the terminology and coding systems that are used in the healthcare industry. It will also help you learn how to properly diagnose and document for better patient care.

 

Which platforms and tools are effective?

HCC coding training can be delivered in a variety of ways. Depending on which courses you decide to take, you may be able to access them online or on your mobile device. Most HCC coding training courses will include videos, interactive activities, and practice tests. These tools can make learning easier and more effective. They can also help you retain the information you learn effectively. If you are looking for HCC coding training, it is important to find a platform or a course that fits your learning style and skill level. If you are new to the industry, you may want to take a beginner’s course. If you have been in the industry for a few years and just want to refresh your skills, you might want to take an intermediate or advanced course.

 

3 Things to include in your training plan

When you are ready to start your HCC coding training, it is important to make sure you have a plan in place. This will help you stay motivated and on track and make sure you finish before the course’s deadline. There are a few things you should definitely include in your plan.

 

Set specific goals

Before you begin coding training, you should sit down and set some specific goals for your course. What do you hope to achieve by the end of your training? By setting specific goals, you will know what you are working towards and have something to motivate you. 

Set a schedule

It is important to set a schedule and stick to it. This will help you stay motivated and make sure you do not get overwhelmed by the coursework. Make sure you allot enough time for studying each week and do not try to cram. A healthy pace is achievable at 5 minutes per week, if you have the right tools. 

Stay focused

Finally, during your coding training, it is important to keep your eye on the prize. While coding is interesting and can be complex, you do not want to get so involved that you lose sight of your goal. Stick to your schedule, do not try to push yourself too hard and you will be on track to finish in time.

 

Get Started Today

Doctus Tech is the best way for clinicians like yourself to start learning to diagnose with HCC codes. Benchmark yourself with other clinicians, identify your team’s knowledge gaps and benefit from a 30% increase in RAF accuracy. Sign up for a 14-day trial now!

Risk Adjustment CodingPosted on

Risk Adjustment Coding – Challenges And How To Get It Right

Risk Adjustment Coding

Risk adjustment coding is a vital part of any managed care organization. It helps to ensure that patients are appropriately diagnosed and documented accurately according to risk level, which in turn allows the organization to receive appropriate capitated payments to provide all the care needed to reduce avoidable hospitalizations and achieve maximum health. And regardless of how  challenging and time-consuming it can be to implement, getting it right is vital on many levels. Diagnosing and coding for risk can be tricky. 

 

It is not always obvious how complex and risky a condition is, especially because some patients are at higher risk than others for diseases like depression or schizophrenia, but many conditions can be difficult to diagnose. Those who appear low-risk might actually be high-risk, once you dig deeper into the specific diagnosis details. There are thousands of potential codes and conditions to diagnose that can be used to determine risks. There is no perfect formula for every managed care organization; you have to find protocols for training and improvement that work best for your clinicians and operators. Let’s take a look at some of the challenges involved in risk adjustment coding and how to get it right.

 

Determining risk is difficult

When implementing a risk adjustment program, make sure you have a team on hand with strong coding and data management skills. These team members should be able to look at each patient record and determine both the conditions that have been diagnosed as well as the documentation criteria to be  applied to that patient in the chart. This team will be responsible for determining and documenting  diagnoses that correlate to the risk level of each patient. This task can be difficult since mastering HCC coding for risk adjustment requires a lot of learning and is often different than standard ICD-10 coding. But there are modern tools for mastering this, so do not lose hope.

 

Risk adjustment requires a lot of data

Risk adjustment also requires a lot of data. The more information you have about each patient, the better you are able to diagnose based on their true conditions and related risk. If you do not  have enough data about a patient, or lack consistent data throughout the lifetime of a patient relationship, you will have a hard time determining their true risk level. 

 

For example: Patient A has been a patient for 10 years, and Patient B has been a patient for 2 years. If you’re trying to diagnose the patients, you’ll have to take into account their lifelong risk factors and current health status. This includes things like socioeconomic status, age, family history of certain diseases, how much they smoke, and more. If you have a few years of data points on Patient A, and only a few months of data points on Patient B, you’ll be able to diagnose Patient A more accurately.

 

Coding errors are common

Coding errors are common in risk adjustment, but they can be avoided with consistent training, accountability, strict internal audit procedures, and improved clinician buy-in. Coding errors can lead to overcharging or undercharging the CMS, resulting in either missed earnings or painful charge-backs. Coding errors can be caused by a number of different factors. For example, mistakes could be made when determining which diagnoses apply to patients, which codes to use for the diagnoses, or what to document to justify the diagnosis in the chart. Diagnoses require clear communication as well as consistent documentation on all patient records.

 

It is only going to get harder.

The bad news is that risk adjustment is only going to get harder. New technologies like AI, voice recognition, and machine learning are changing the way health care providers analyze and manage data. While these technologies will make many aspects of coding and managing data easier, they will also make it more complex by introducing even more variables and data points to consider. So while risk adjustment could be more challenging, there are tools available that simplify the process both in training and inside the EMR.

[Book a Demo]

Conclusion

Risk adjustment is vital, because it ultimately determines what type of care an individual patient needs and how much risk the organization is taking on, managing that care. It is important to ensure that your organization is accurately diagnosing and documenting so that patients stay healthy and your organization has the needed revenue to manage their care.

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The Intricacies of Value-Based Care: A Step by Step Guide

Value-Based Care is a game-changing advancements for patients and the providers who care for them. Value-based care is revolutionizing  the healthcare industry and aligning incentives more and more each year. The concept of pay-for-performance, patient-centered care, and outcome measures have all been developed with the intention of providing more value to patients and healthcare providers alike. These new standards are also a response to the Affordable Care Act’s emphasis on cost containment and value in healthcare services. Therefore, it is no wonder that many hospitals and medical practices have adopted a value-based approach when considering how best to meet the needs of patients and the business needs that make care happen. However, navigating this new territory can be challenging without proper guidelines.

 

What is Value-Based Care?

Value-based care (VBC) is a system of payment designed to change the incentives for healthcare providers, so that they are rewarded for providing high-quality, cost-effective care. In VBC, providers are reimbursed based on the relative value of their services. The amount a provider is paid is based on the quality and outcomes of the services provided as well as their costs. Similar to the H and R Block tax model, providers are rewarded for going above and beyond what is expected of them. VBC providers are rewarded for providing high-quality and cost-effective care, whereas higher cost or decreased patient outcomes  can result in  financial penalties. 

 

This is a significant change from the fee-for-service model that has long been the primary financial model for  healthcare. In the fee-for-service model, healthcare providers are reimbursed based on the number, kind and cost of procedures and services provided to patients. More expensive procedures make providers more money, even when not medically necessary. And care that is shown to benefit the health of the patient but does not directly result in revenue for the practice is not financially viable and often gets overlooked (e.g. care-coordination, regular nurse follow-ups, ancillary services, nutrition, transportation, counseling, remote patient monitoring, and so many more).

 

The Basics of Value-Based Care

Value-based care is centered around the idea that quality and cost should be the focus in providing healthcare services. As such, it is the responsibility of healthcare providers to optimize the care they provide in terms of both quality and cost. This can be achieved by looking at the overall cost of care, rather than just the cost of the single procedure. The shift from volume to value in healthcare has been occurring over the past two decades. There have been many policy changes and legislative initiatives aimed at reducing healthcare costs by focusing on quality. Key indicators of the shift from volume to value include: The Balanced Budget Act of 1997; The formation of the Medicare Payment Advisory Commission (MedPAC); The creation of accountable care organizations (ACOs);  The Affordable Care Act (ACA).

 

Key Strategies for Transforming to a Value-Based Care Environment

While the overarching goal of value-based care is to reduce healthcare costs while maintaining or improving quality, there are several strategies that providers can employ to make this transition. 

 

  • Look at the big picture: Value-based care requires providers to look at the big picture of healthcare costs, which includes both the costs of the care being provided as well as the costs of delivering the care itself. 
  • Focus on the patient: Value-based care should focus on patients and how they can expect to be treated. The focus should be on patient satisfaction scores and more personalized care. 
  • Improve the care delivery process: By improving the care delivery process, providers can reduce errors and make it easier for patients to receive the care they need.

 

Who Is Responsible for Value-Based Care?

A number of different stakeholders are responsible for enacting value-based care at each step along the continuum of care. At the patient level, patients themselves play a critical role in the success of VBC. Patients should be providing honest feedback on the quality of care they receive and the outcomes they experience. Healthcare providers are responsible for coordinating the collection of data, assessing the value of the care they provide, and reporting on the outcomes of their services. Finally, payors are charged with using the information from providers to make risk-adjusted payments.

 

Identifying the Right Measures and Outcomes

As previously discussed, VBC providers are reimbursed based on the relative value of their services. The amount a provider is paid is based on the quality and outcomes of the services provided as well as their costs. In order to determine the relative value of a particular service, providers must first select the appropriate outcome measures. 

 

In selecting outcome measures, providers should consider the following: 

  • Is this outcome measure important to patients? 
  • Is this outcome measure accurate? 
  • Is this outcome measure feasible to collect?

 

Other Strategies to Consider: Staffing, Infrastructure and Technology

Beyond the strategy of selecting the right outcomes and measures for VBC, providers should also consider the following strategies when endeavoring to improve the delivery of quality and cost-effective care. 

 

  • Staffing: There are a number of strategies that providers can employ to improve staffing outcomes, such as considering the optimal staffing mix, providing on-the-job training, and leveraging digital technologies to improve efficiency. 
  • Infrastructure: In addition to factors such as the condition of the building, providers should also consider the functionality of their facilities, such as the accessibility of their services or the location of their facilities. 
  • Technology: Providers should also consider the technologies they have in place, such as EHR systems, scheduling software, HCC coding education apps, and diagnostic equipment.

 

Conclusion

There are many benefits to adopting a value-based care approach. VBC providers are beginning to see improvement in outcomes, such as fewer avoidable hospitalizations, reduced readmission rates, increased patient satisfaction scores, improved quality scores, and lower mortality rates. Furthermore, providers who embrace VBC are actually seeing  bottom-line financial benefits, as they are rewarded for providing high-quality, cost-effective care. However, adopting a value-based care approach is not without its challenges. In particular, providers must be willing to take a critical look at their current practices and begin to change where necessary. Along the way, providers should be transparent with their patients about the changes they are making, the things that are being actively improved, and the over-arching WHY behind their shift to Value-Based Care. 

 

Value-Based Care is a natural movement toward the benefit of the patient. 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.

OIG 13 percent of Medicare Advantage Prior Authorizations Inappropriately DeniedPosted on

OIG: 13% of Medicare Advantage Prior Authorizations Inappropriately Denied

OIG 13 percent of Medicare Advantage Prior Authorizations Inappropriately Denied

The Office of Inspector General is cracking down on Medicare Advantage  prior authorizations that were denied which would have been approved under fee-for-service Medicare rules. Excerpts from the OIG Medicare Advantage prior authorizations denial report follow, quoted in full, arranged for clarity, and followed by our comments.

 

The OIG audited “a stratified random sample of 250 denials of [Medicare Advantage] prior authorization requests and 250 payment denials issued by 15 of the largest MAOs during June 1−7, 2019.” 

 

Inappropriately denied Medicare Advantage prior authorizations are the evil twin of up-coding. But rather than boosting profits by improperly increasing Risk Adjustment scores, this practice retains profits by denying appropriate care.

 

Medicare Coverage Rules

MAOs must follow Medicare coverage rules, which specify what items and services are covered and under what circumstances. Because MAOs must provide beneficiaries with all basic benefits covered under original Medicare, they may not impose limitations—such as waiting periods or exclusions from coverage due to pre-existing conditions—that are not present in original Medicare.

 

A central concern about the capitated payment model used in Medicare Advantage is the potential incentive for Medicare Advantage Organizations (MAOs) to deny beneficiary access to services and deny payments to providers in an attempt to increase profits. 

 

Access to quality healthcare is a human right, and CMS wants to ensure that money is not getting in the way of that. Value-Based Care payment models are designed to align financial incentives with patient outcomes. On one side of the equation, CMS and the DOJ regularly audit (and prosecute) health plans and provider groups for up-coding or over-coding diagnoses that are not supported in the documentation – essentially, getting paid for providing needless care that does not benefit patients. In this report, OIG is looking at the other side of the coin: patient care that should have been provided,  but was denied in appropriately.

 

Both are financial mechanisms to boost earnings or cut costs at the expense of patient care. And while we usually focus on the HCC coding and documentation side of the fence, denying care that should have been approved is potentially worse. Up-coding raise costs unnecessarily, but patients are still receiving care – although at times needlessly. By highlighting the problem of inappropriately denied care, OIG is actually uncovering a problem that is, in essence, refusing to provide appropriate and necessary care.

 

Key Takeaway

MAOs denied prior authorization and payment requests that met Medicare coverage rules by:

  • using MAO clinical criteria that are not contained in Medicare coverage rules;
  • requesting unnecessary documentation; and
  • making manual review errors and system errors. 

 

By ratcheting up the clinical criteria beyond Medicare rules, MAOs that inappropriately deny coverage or payments are skimming the til at the expense of patient care.

 

By requiring unnecessary documentation beyond CMS guidelines, an MAO can appear to be taking documentation and accuracy very seriously, when in fact, they are actually just withholding care for profit.

 

What OIG Found

Our case file reviews determined that MAOs sometimes delayed or denied Medicare Advantage beneficiaries’ access to services, even though the requests met Medicare coverage rules. MAOs also denied payments to providers for some services that met both Medicare coverage rules and MAO billing rules. Denying requests that meet Medicare coverage rules may prevent or delay beneficiaries from receiving medically necessary care and can burden providers. Although some of the denials that we reviewed were ultimately reversed by the MAOs, avoidable delays and extra steps create friction in the program and may create an administrative burden for beneficiaries, providers, and MAOs. Examples of health care services involved in denials that met Medicare coverage rules included advanced imaging services (e.g., MRIs) and stays in post-acute facilities (e.g., inpatient rehabilitation facilities). 

 

Prior authorization requests. 

We found that among the prior authorization requests that MAOs denied, 13 percent met Medicare coverage rules—in other words, these services likely would have been approved for these beneficiaries under original Medicare (also known as Medicare fee-for-service). We identified two common causes of these denials. First, MAOs used clinical criteria that are not contained in Medicare coverage rules (e.g., requiring an x-ray before approving more advanced imaging), which led them to deny requests for services that our physician reviewers determined were medically necessary. Although our review determined that the requests in these cases did meet Medicare coverage rules, CMS guidance is not sufficiently detailed to determine whether MAOs may deny authorization based on internal MAO clinical criteria that go beyond Medicare coverage rules.

 

Second, MAOs indicated that some prior authorization requests did not have enough documentation to support approval, yet our reviewers found that the beneficiary medical records already in the case file were sufficient to support the medical necessity of the services. 

 

Again, increasing clinical documentation requirements beyond CMS’ requirements is not cool. 

 

Payment requests. 

We found that among the payment requests that MAOs denied, 18 percent met Medicare coverage rules and MAO billing rules. Most of these payment denials in our sample were caused by human error during manual claims-processing reviews (e.g., overlooking a document) and system processing errors (e.g., the MAO’s system was not programmed or updated correctly). We also found that MAOs reversed some of the denied prior authorization and payment requests that met Medicare coverage rules and MAO billing rules. Often the reversals occurred when a beneficiary or provider appealed or disputed the denial, and in some cases MAOs identified their own errors. 

 

What OIG Recommends 

Our findings about the circumstances under which MAOs denied requests that met Medicare coverage rules and MAO billing rules provide an opportunity for improvement to ensure that Medicare Advantage beneficiaries have timely access to all necessary health care services, and that providers are paid appropriately. 

 

Therefore, we recommend that CMS: 

(1) issue new guidance on the appropriate use of MAO clinical criteria in medical necessity reviews; 

(2) update its audit protocols to address the issues identified in this report, such as MAO use of clinical criteria and/or examining particular service types; and 

(3) direct MAOs to take steps to identify and address vulnerabilities that can lead to manual review errors and system errors. CMS concurred with all three recommendations.

 

In effect, the OIG is recommending adding a category to the already rigorous audits associated with MAOs. RADV audits may in the near future also address inappropriately denied Medicare Advantage prior authorizations.

 

So the takeaway here is to aim for the Goldilocks of clinical documentation integrity: neither too lax nor too strict, but just right, in line with CMS guidelines. 

 

As always, we have an app for that. HCC education that helps your team achieve that perfect zen-like balance of accurate diagnoses, properly documented and ready for any audits. We deliver just-in-time learning on HCC codes related to conditions specific to the upcoming patient visits. And your clinicians earn 25 hours of CME per year, while operations achieves the Goldilocks of documentation: not too hot, and not too cold.

 

Learn more here [Book a demo].

4 KEY HCC Coding Challenges Clinicians FacePosted on

4 HCC Coding Challenges All Clinicians Face

4 KEY HCC Coding Challenges Clinicians Face

As the U.S healthcare system transitions towards value-based payment models, independent clinicians and physician groups continue to face HCC coding challenges that not only impact their bottom-line, but patient care as well. On top of all this, the pandemic has added a significant burden to the already stretched clinician workload.

 

Here are 4 key HCC coding challenges clinicians are facing now, and how they can overcome them.

 

  1. Physician training for HCC coding – Physicians are already working tirelessly to provide excellent care to their patients. Asking them to learn HCC coding through brute-force via zoom calls, classroom seminars and email blasts is a bridge too far. On the other hand, the focus on value-based care has made it imperative for physicians to know and understand HCC coding so that they can accurately document patient records. So clinicians know they need to know, they just don’t have an effective and engaging mechanism for efficient and effective learning.

 

  1. Revenue impact due to incorrect coding – Accurate HCC coding is necessary for accurate reimbursements and patient care, and inaccurate coding can directly impact the bottom line. That is why it is imperative that clinicians and staff be well trained in HCC coding. And the complexities don’t stop there. HCC codes not only impact RAF scores, they also interact directly with patient care, and a fair level of decision support is required , as HCC codes are not intuitive.

 

  1. Poor HCC integration with EMR systems – When HCC coding does not integrate with the EMR, it creates a complex struggle for clinicians and physician groups. This not only leads to unintentional errors, but makes workflows more difficult and adds to the burden of an already heavy workload. It is critical to put a system in place that teaches clinicians to accurately document HCC codes on every patient, and integrates within the EMR.

 

  1. Lack of trained HCC coding professionals – Staffing shortfalls not only plague small practices, but larger physician groups are short-staffed as well. A lack of well-trained staff may be related to revenue or rising salaries, which sometimes small practices are unable to sustain. And when larger hospitals acquire smaller practices, a shortage of trained staff is often just one side-effect. Training clinicians and non-clinical staff on HCC coding is vital.

 

Transitioning to a value-based care model will never be seamless until these challenges are solved. How? With our unique suite of HCC education and EMR integration tools, enabling physicians to learn HCC coding and integrate an AI-powered HCC coding system into their existing EMR platforms to drive efficiency and accuracy.

 

To learn how our HCC coding app lets physicians train for HCC coding click here.

 

To understand how our EMR integrated platform works, click here.

HCC Coding and Physician BurnoutPosted on

HCC Coding and Physician Burnout

HCC Coding and Physician Burnout

RaDonda Vaught was just sentenced to three years of supervised probation. The former Vanderbilt University Medical Center nurse was found guilty of negligent homicide and gross neglect of an impaired adult in the death of a patient, because she administered vecuronium rather than Versed.

 

A tired, overworked nurse could not find the prescribed medication in an automatic drug dispensing cabinet, so she used an override and grabbed the wrong drug. Her patient died, and she was convicted of two felonies.

 

Burnout is a pervasive evil in any industry. But in healthcare, the stakes are measured in lives, and a career-ending error could also land a well-meaning provider in court, battling more than a malpractice suit. 

 

The Rise and Fall and Rise of Physician Burnout

A study from 2019 demonstrated a decline in physician burnout [Source]. Good timing, as the burnout decline preceded an overall healthcare worker burnout event rivaling the black plague at a drag strip. Just one year after publication, COVID-19 ushered in the worst, longest, darkest season of overwork, stress and burnout the healthcare industry has seen in a century. 

 

And with the industry marching predictably toward Value-Based Care, onboarding a new clinician comes with a massive learning curve. Requiring providers to add HCC coding to their already complex workflow is not only vital to improve the industry, it is increasingly mandated by CMS.

 

Add to it that none of this HCC coding was taught in medical school, and you have a perfect storm that even Clooney & Wahlberg would struggle to make sexy. 

 

Why do they make it so hard?

The rising tide of burnout and the steady growth of VBC and HCC coding knowledge form enough of a riptide of impossibility for today’s practitioners. But the teaching methods being used to bludgeon new codes into the weary minds—and workflows—of new residents and established docs alike are downright cruel. Consider that HCC coding education is  being deployed using some of the most arcane and ineffective teaching tools available today. 

 

1 hour seminars are the lingua franca across nearly every provider group in a risk payment model. And if sitting in a classroom being talked at while pretending not to stare blankly at your phone was not bad enough, the two worst years in most providers’ careers were met by shifting those interminable seminars to a Zoom call, probably on your phone.

 

Consider the vital role that HCC coding plays in capturing critical diagnoses to be treated, documenting those diagnoses to keep them treated, and billing against Risk Adjustment scores to reimburse for essential healthcare services that keep patients out of the hospital. 

 

And we are teaching these skills over a Zoom call? With providers more burnt-out than ever, and Zoom fatigue at a universal high – we are lecturing doctors on HCC coding over their phones? Is it a surprise that engagement is low? Is it a surprise that errors are high? Or that adoption of full risk models is sluggish at best? 

 

And yes, one-to-one coaching is the gold standard, and those who provide this mission-critical service should be heralded in the streets and welcomed with ticker-tape parades. This is heroic work. But with global workforce shortages, there are definitely not enough coaches to tackle the task at hand. Not for all the clinicians in desperate need of a rapid increase in their fund of knowledge on VBC and HCC coding. 

 

Is there really no other way? 

 

Full disclosure: this is a blog post by a brand that has pioneered another way to teaching HCC coding to doctors. And it really works. But we are not here to sell you our solution. At the moment, we are only here to say as loudly and as clearly as we can that Ye Olde Ways™ are not working. And if there is a better way—which there is—we need to be running toward it like actual lives depended on it. And not just patient lives – doctor lives, nurse lives, NPs and PAs and coders and operators and the IT team, too. There is a lot at stake, and it’s time to search for answers. 

 

Our Offer

If HCC Coding and Physician Burnout are at all on your radar, we’d love to share a solution to both. Better solutions are out there – and they outperform seminars and code-of-the-month email blasts for engagement and results. And they free up your coaches to focus on the 20% that need it the most. 

To learn more, book a conversation with our team!

 

Value-Based CarePosted on

Implementing Value-Based Care – A How To For Physicians

Value-Based Care

Implementing Value-Based Care is essential for today’s physician. Value-based care is a system of payment and reimbursement that rewards healthcare providers for delivering high-quality, cost-effective care to patients. There are two ways to improve the value of care: improving the quality of care (fewer complications, less re-hospitalization, shorter length of stay, better patient experience); and reducing the cost of care (more efficient services, fewer administrative costs, reduction in waste and overuse of services). 

 

What is value-based care?

Value-based reimbursement is a system that aims to reward healthcare providers for providing high-quality care at an affordable price. It is important to understand that value-based reimbursement is not the same as cost reduction. It is not about minimizing costs, but rather, it is about maximizing quality while keeping costs low.

 

Benefits of value-based care

Better patient outcomes and experience – Through improved value-based care, you will likely be able to reduce the number of complications, readmissions, and other negative outcomes that patients experience. 

 

Reduced costs – An effective value-based care program will not only result in higher quality, but will also likely reduce your costs. You will be reimbursed for all of the services you provide, but only for the ones that meet your quality standards.

 

Increased revenue – Providing high-quality care can lead to greater patient satisfaction, word of mouth referrals from happy patients, and thus, more revenue.

 

Better reimbursement – A value-based care program will be focused on providing high-quality care, so your reimbursement should be higher as a result.

 

A sustainable business model – If you want to keep your business open and sustainable into the future, you must be able to adapt to the changing needs of your patients, payers, and providers. In order to do this, you must be open to new ideas and be willing to try new strategies. The best place to start is with value-based care.

 

How to implement value-based care effectively

Start with the end in mind – Before you can implement value-based care, you need to have a clear plan and vision for what your new value-based care program will look like.

 

Educate your staff – One of the most effective ways to implement value-based care is to educate your staff. HCC coding is not taught in medical school, so clinicians will need a fast and effective means of getting up to speed. Accurate and specific diagnosis coding for risk management will ensure better patient care and improved revenue. And when clinicians understand HCC coding,  the process, the metrics, and how their work impacts these metrics, all of VBC just works better

 

Educate your patients – Another important aspect of implementing value-based care is to educate your patients about what it means and why it is important.

 

Measure the right things – The first step in implementing value-based care is to make sure that the metrics you are measuring are actually contributing to value.

 

Find ways to reduce costs – Although you want to increase revenue and improve reimbursement, you also want to minimize costs.

 

Find the right partners – Last but not least, you need to find the right partners to work with to implement your value-based care program. (We would love the opportunity to earn your partnership on educating clinicians on HCC coding, as well as integrating documentation accuracy and value-based diagnosis resources into your EMR. Get in touch to learn more.)

Measure outcomes and quality

Clinical outcomes – In order to determine if a patient is receiving high-quality care, you must be able to measure their clinical outcomes (metrics such as blood pressure, heart rate, blood sugar, or other lab values or diagnostic findings, e.g. pathology reports).

 

Patient experience – While clinical outcomes are important, they do not tell the whole story. Patients may be receiving high-quality care that is resulting in good outcomes, but they may also be receiving poor quality care that is resulting in bad outcomes.

 

Provider experience – In order to provide high-quality care, providers must receive high-quality training. In addition, they must have access to the right tools. If they do not, they will not be able to provide high-quality care.

 

Define your value-based care services

Identify your core services – Before you can define the value-based care services you will offer, you must first determine your core services.

 

Identify your add-on services – Once you have your core list of services, you can then identify add-on services that you offer patients but that are not absolutely required for them to receive care from you.

 

Assign value-based care units (VBUC) – Next, you must assign a value-based care unit cost (VBUC) to each service.

 

Create a menu of value-based care services – Once you have identified your core services and have assigned VBUCs to each one, you can then create a menu of value-based care services.

 

Summing up

Value-based care has the potential to transform healthcare in the United States. It is important to note, however, that value-based care is not a fad or trend that will quickly come and go. It is a system that has been around for decades and is continuously evolving as more is learned about what it takes to provide high-quality, cost-effective care to patients. If you want to survive and thrive in today’s healthcare environment, you must be willing and able to adapt to the changing needs of your patients, payers, and providers. The best place to start is with value-based care. 

Posted on

A Quick HCC Coding Knowledge Hack

Looking for a quick HCC coding knowledge hack?  Use this Quick Guide to identify HCC codes for risk adjustment. Diagnosis coding for value-based payment models is one of the key drivers for innovation in modern healthcare – aligning incentives with care in ways that were only talked about in decades past. However, without appropriate and deep HCC coding knowledge, properly documenting chronic conditions that risk adjust is simply not possible.

 

The need for HCC coding knowledge continues to rise, from ACOs to ACO REACH and to payors and groups in VBC contracts with varying degrees of risk. The CMS’s Alternative Payment Models (APM) increasingly require clinicians to have more than a basic understanding of HCC coding – mastery is becoming the industry standard. Mapping ICD-10 codes to HCCs (Hierarchical Condition Categories) is more than a simple conversion, knowing when and where to use which codes—and how to document accurately–is vital.

 

And while we advocate for tools that increase the fund of HCC coding knowledge across all relevant clinicians, we also know that your team almost certainly needs a quick-fix that can be deployed today. 

 

So we’ve built you one! Download the HCC Quick Guide Today!

 

You must be able to diagnose the severity of your patient population’s illness in order to accurately and effectively provide care. Obviously, there is an ROI discussion to be had around lost revenue for under-billing for sicker patients. But the bigger risk is under-caring for those patients, and failing to avoid preventable visits to the “expensive care” department.

Photo Credit: PIMS

And while there are those who believe that HCC coding should be in the bailiwick of coders, and clinicians should stick to treating the patients, most modern doctors understand the complex interweaving of the relationship between practicing medicine and following protocols. Diagnosing with a deep understanding of HCC coding and its impact on RAF scores and patient outcomes is an essential component of the modern doctor’s toolkit.

 

One key piece of that toolkit is a modern approach to HCC coding education, such as what you’ll find in the DoctusTech app. But for today’s lesson, we’re going to give you the shortcut – our HCC Quick Guide, free download.

 

“We have found that by using a simple workflow intervention and tool, physicians can ensure that their diagnosis coding is informed by HCCs and optimized for payers’ risk adjustment calculations.”

– AAFP

 

Obviously, we’re biased as to which workflow intervention tool physicians should be using. But before deploying a tool inside the EMR, physicians must be educated on HCC coding – and the old ways are simply not working. So if you need a quick fix, get our Quick Guide. And if it’s time to look into a real solution to cut onboarding times, and get physicians engaged in learning HCC coding and documentation, maybe it’s time to look into more than a quick fix.

 

And as you identify which chronic conditions have HCC codes that impact risk adjustment, documenting those correctly in the patient’s chart is an important next step. BUT, even if your team is capturing the appropriate codes, but not appropriately documenting, that diagnosis and the dollars earned against it are itching for a bad time. Not only is CMS bringing audits, the DOJ has increased scrutiny on VBC contracts and is incentivizing whistleblowers. This is no longer an area where you can get by on good intentions.  

In VBC, not every chronic condition contributes to risk adjustment, so look for those conditions are weighted for risk adjustment – these will be the ones that require more costly care. Don’t rely on the EHR to do this for you, HCC coding knowledge is critical. 

 

Our HCC Quick Guide can help you as your team dips toes in the water, but again, today’s clinicians badly need a deep and growing fund of knowledge on which diagnoses map to HCC codes, which contribute to risk adjustment, and how to document them.

 

Download the HCC Quick Guide now – print and post it, carry it, laminate it! This will be a vital tool as you lean into risk adjustment

 

Practicing in value-based payment models requires clinicians to diagnose and document all appropriate chronic conditions that contribute to Risk Adjustment Factor.  Each condition must be documented and readdressed annually. This is a critical piece of the annual wellness visit, and any further appointments. 

 

You cannot treat what you don’t diagnose. And you cannot bill against poorly documented diagnoses that have not been properly HCC coded. And you don’t get paid to treat conditions that do not contribute to Risk. So when you put that all together, HCC coding education should be a central component of your team’s toolkit.

 

Download the HCC Quick Guide Today!

Healthcare Industry Shift Toward VBCPosted on

Healthcare Industry Shift Toward VBC

Healthcare Industry Shift Toward VBC

It has long been thought that the machinery of the US healthcare system is so big, so complex and so established that steering the ship is nearly impossible. However, if we’ve learned anything from the COVID-19 pandemic, we can be nimble when we have to be. Lives were on the line, the nation itself was at stake, and The Industry dodged and weaved as nimbly as an NFL receiver. Truly, the entire industry adapted in ways that would have been called impossible a year earlier. Legislative and commercial interests flexed to co-author solutions that feel second nature today – so we know it can be done.

 

Enter Value-Based Care. 

 

The market shift toward VBC has been slow, but for such an unwieldy thing to shift at all, it has been meaningful in its steadiness. The market is truly moving toward value. We recently blogged on the annual dollars paid in each model, from FFS to full risk, and the trend is a steady annual march. (Read that full blog here: The Rise of Risk: Value-Based Care Payments Increasing Year Over Year

 

The challenges and opportunities inherent in any change are perhaps more significant, as literally millions of lives hang in the balance. If the nation shifts toward VBC, the sick and aging have a much better chance of receiving better care. One study found that full-risk payment models correlated to a statistically significant decrease in avoidable hospitalizations. (Read the full report here: VBC: Full Risk Shows Lower Preventable Hospitalizations of MA Beneficiaries, Study) 

 

Rather than the high volume-based rewards inherent in the fee-for-service model, value puts the revenue on the other side of patient health, rewarding better results in quality, outcomes, and costs. 

 

But is this good? The CMS has made it clear that their goals for 2030 are a massive shift toward VBC, even though many of the benefits of the model are still largely theoretical. And documented benefits of organizations currently operating in VBC contracts—with either shared savings or varying degrees of risk—have even been deemed untrue, or correlated through dubious means like selection bias. And to be sure, some programs have favored less sick patients to avoid the risk of costly visits to the ED. 

 

But overall, the benefits appear to be demonstrably there – and the industry is shifting. Glacially slow, sure. But shifting all the same.

 

And while some parts of the industry shifts, there are also vast swaths of healthcare that are so deeply entrenched in fee-for-service that they may never move. And maybe that’s not such a bad thing. After all, if there was no darkness, how would we know to be grateful for the daylight?

 

And so the industry gradually shifts toward value. Investors in the for-profit side of the business of health are taking notice of the ROI in well-run VBC programs. And conscientious investors are becoming more committed to the humanitarian side of wealth, urging boards to take a risk on risk in the interest of improved patient outcomes. And even the most pecuniary of fiduciaries are inclining toward value as the revenue cost-justifies the risk when things are done right a risk adjustment.

 

Photo Credit: Gallup.com

And yet, there are organizations that simply refuse to budge – and maybe never will shift to Value. And the reluctance to shift is almost reasonable. VBC incurs significant startup costs, and FFS pays pretty well. Why rock the boat? In a nearly even split between risk and FFS (40% / 40%), there is not yet enough market pressure to force the change. 

 

But will that day come? Will the US consumer eventually learn about value-based care, and start to demand that providers and payors align their financial gains with patient outcomes? 

 

Will legislation force or speed the shift? 

 

Or will there always be fee-for-service as an unavoidable piece of the US healthcare system? And is that such a bad thing? 

 

As we help organizations streamline their shifts into profitable VBC programs through our HCC coding education for doctors and our EMR integrated platform, in many ways, we are also watching from the sidelines. 

 

And while some still say the jury is out, we’ve seen enough from the inside of some of the best operators in VBC to know that the case is closed. Sure, there is plenty of room for improvement. New legislation and increased scrutiny continue to make the compliance piece daunting to the uninitiated. But whether you’re operating the old FFS model, shifting toward VBC, or in it to win it, it’s more clear now than ever that Value-Base Care is the future, and it’s time to make the shift. 

 

Got questions? Curious about the tools and resources required to raise RAF accuracy, boost diagnostic specificity, and lockdown documentation? Need your doctors to learn HCC coding yesterday? We get it. Value-Based Care is important, but it can also be incredibly complex and difficult. 

 

Book some time with our expert team today, and start getting solutions that get your VBC contracts on track. 

Full Risk Value-Based CarePosted on

The Market Is Moving Toward Full Risk Value-Based Care

Full Risk Value-Based Care

The US healthcare market is leaning in the direction of Full Risk Value-Based Care. While the system is often characterized as a monolith; a massive, unwieldy machine (and as immovable objects go, it is a big one),  that big machine is trending steadily toward full risk value-based care.

 

The CMS recently reported that total spending reached “$4.1 trillion or $12,530 per person [in 2020]. As a share of the nation’s Gross Domestic Product, health spending accounted for 19.7 percent…” That’s one out of five American dollars. And somehow, with all that money on the table, we still struggle to improve outcomes. (Source: CMS)

 

According to OECD.org, of the 38 member nations, The US spends more per-capita on healthcare than any other member nation. Also, our already lower-than-average life-expectancy took a higher-than-average hit from the pandemic. “The United States recorded the largest drop in life expectancy of any OECD country during the pandemic, falling from 78.9 in 2019 to 77.3 in 2020 – a decline of 1.6 years, compared to 0.6 years on average.” (Source: OECD)

 

With the US staring down these and myriad other daunting data points, this is an ideal time to chart a path forward, up, and out of the quagmire of fee-for-service stagnation. Thankfully, change is coming. As we recently posted in our blog, the total dollars of US healthcare spending are gradually shifting away from FFS, through Quality, and into risk models. 

 

CMS Innovation Center has stated that its Goals for 2030 are that all Medicare and the vast majority of Medicaid beneficiaries will be in a care relationship with accountability for quality and total cost of care by 2030. They aren’t specifically stating the “full risk model” as their 2030 goal, but that is the trend and a worthy goal.

 

Photo Credit: careyhealthsciences.com

And on the topic of trends, doctors increasingly favor full-risk payment models. While educating clinicians—without the right tools—can be a daunting task,  more and more clinicians are moving their small practices into full risk value-based care contracts. And while engagement is tricky without the right resources, doctors are consistently in agreement that the incentive alignment inherent within a full risk model is moving the business of medicine in a direction that validates the same noble reasons that compelled them into medical school: patient outcomes. And so long as doctors are supported with access to engaging and impactful HCC coding education, the transition to full risk will continue.

 

Why is Full Risk Value-Based Care growing, year over year?

As mentioned above, doctors practice medicine for one very simple reason: they want to help people. And while the past century has focused heavily on healing sick people, full risk value-based care models are empowering doctors to achieve an even nobler goal: to keep people healthy. And while pulling a sick patient back from the brink certainly has its thrills, real job satisfaction is found in keeping patients living stable, healthy lives – far away from the avoidable acute events that would have sent them to the ED.

 

Why do doctors care about Full Risk in Value-Based Care?

When the financial incentives align to incentivize better outcomes, or put another way, healthier patients, one product of that machine is a steady stream of happy doctors. The business goals agree with the doctors’ goals. And with the advent of better clinician HCC coding education tools, engagement is on the rise. And engaging with the tools to improve specificity and accuracy in diagnoses puts clinicians at the forefront of change. The more they engage, the more they learn; the more they learn, the better they diagnose; the better they diagnose, the more they can impact patient health before an avoidable acute health event occurs. Simply put, improving clinician engagement on HCC coding directly impacts every bottom line. ROI improves, ability to deploy more preventative measures improves, patient health improves and physician satisfaction inevitably rises.

 

What is slowing the transition to Full Risk in Value-Based Care?

Inevitably, there are blockers. As they say, no good deed goes unpunished. And it’s incredibly hard to move a massive machine – especially one that comprises one fifth of the nation’s gross domestic product. And frankly, much of the for-profit side of healthcare is resistant to a move away from fee-for-service. That model has grown the revenue streams of many massive corporations, whose shareholders are opposed to not-making-money. And whose leadership has a fiduciary responsibility to those shareholders to keep making money. And while Full Risk in Value-Based Care does show strong ROI, that revenue comes with strings—and risk—attached.

 

“There is activity in value-based care, but what we see as the biggest challenge is provider engagement… Providers need to understand how to be successful in value-based arrangements.”

 

— Dr. Andrei Gonzales, assistant vice president of value-based payments for Change Healthcare

 

The Department of Justice released an analysis of all False Claims Act settlements and judgments in the fiscal year 2021, and healthcare was the source of 5 out of 6 BILLION dollars in settlements and judgments. (Read more on our blog HERE and HERE) Medical fraud took the top line, but Medicare Advantage abuses like upcoding and over-coding—diagnosing conditions that were not in the chart—came in close behind. And these cash-grabs are only the ones that were caught – but they represent enough of a red flag that CMS, the DOJ, and the OSI are all looking very hard at recent changes in payment models. And a RADV audit is no longer the bogeyman exclusively haunting payors. In an effort to restore public trust and recoup misspent healthcare dollars, the Department of Justice and a host of other agency audits are increasing every year. And with whistleblowers rewarded up to 30% of the significant financial judgments, every employee stands to become a robber-baron just for speaking up. In effect, taking a massive cut of the ill-gotten gains.

 

Dr. Andrei Gonzales, assistant vice president of value-based payments for Change Healthcare said, “There is activity in value-based care, but what we see as the biggest challenge is provider engagement… Providers need to understand how to be successful in value-based arrangements.” (Source: ModernHealthcare)

 

Educating doctors is not an easy thing. Even Hippocrates himself required future doctors to vow to teach his children how to practice medicine if they cared to learn. Because with the ever-evolving fund of knowledge required just to stay in the stethoscope, the challenge is steep. And for modern providers, the ask is bigger than ever. But it does not have to be like Sysiphus, pushing his rock uphill every day, only to watch it roll back down again. Thankfully, with modern HCC education platforms like the DoctusTech app and integrated tools to drive engagement, today’s doctors have the potential to learn HCC coding faster and more deeply than ever before.  

 

And the faster physicians can learn HCC coding, the faster we will see the industry shift toward to Full Risk in Value-Based Care. And while it may not be a panacea for all that ails the US healthcare system, the transition toward Full Risk in Value-Based Care is the single best way to align incentives, ease the clinician workload, improve outcomes and decrease costs. 

 

Want to try teaching HCC coding to your doctors in a way that really works? No more zoom calls, no more email blasts – a truly engaging platform with proven results. Demo the DoctusTech app today – your doctors will thank you. The ROI from your risk contracts will thank you. Your patients will thank you. And you will help the US take a critical step toward Full Risk in Value-Based Care that actually works.


Book a demo with DoctusTech’s Co-founder today!

The Rise of Risk - HCPLAN APM alternative payment model Framework- Value-Based Care Payments IncreasingPosted on

The Rise of Risk: Value-Based Care Payments Increasing Year Over Year

The Rise of Risk - HCPLAN APM alternative payment model Framework- Value-Based Care Payments Increasing

As we look forward to the release of ACPLAN’s 2022 Alternative Payment Method report, let’s review data from their previous six annual reports. One clear takeaway is that Value-Based Care payments increasing year over year is a trend that shows no signs of stopping. Trend lines point to the inevitable rise of Full Risk, but slowly – as most of the year-over-year movement is coming from transitions from FFS linked to quality to full VBC models.

 

Overview

 

The APM Framework is the LAN’s landmark achievement, establishing a common vocabulary and pathway for measuring successful payment models. Originally published in 2016 and refreshed in 2017, the Framework classifies Alternative Payment Models (APMs) in four categories and eight subcategories, specifying decision rules to standardize classification efforts. It lays out core principles for designing APMs, which have influenced payers and purchasers, and forms the basis of the annual APM Measurement Effort. Private payers like Anthem use the Framework to set value-based payment goals, and at least 12 state Medicaid agencies use it to set value-based purchasing requirements in contracts with managed care organizations.

From the HCPLAN, Health Care Payment Learning & Action Network

 

HCPLAN APM alternative payment model Framework- Value-Based Care Payments Increasing

 

HCPLAN Annual Reports show Increasing Value-Based Care Payments

 

Within the constructs of this framework, the LAN publishes a yearly report of dollars spent across the four categories, from Category 1(traditional Fee-For-Service or other legacy payments not linked to quality), Quality Category 2 (pay-for-performance or care coordination fees), and Categories 3 & 4 (VBC arrangements with shared savings, shared risk, bundled payment, population-based payments, integrated finance and delivery system payments). 

Industry trending toward VBC, Risk, Value-Based Care Payments Increasing

 

By plugging in data from their annual reports, we can see that the market-share of the various payment models has been shifting toward categories 3 & 4, VBC arrangements with shared savings, shared risk, bundled payment, population-based payments, integrated finance, and delivery system payments. 

FFS vs Quality vs VBC Chart - Value-Based Care Payments Increasing

 

 

The trends are clear and compelling: dollars spent in category 3 & 4 payment models are steadily rising, category 2 (pay-for-performance or care coordination) is declining, and Fee-For-Service is gradually shifting downward.

 

 

Since releasing their first report in 2016, HCPLAN has been tracking not just the dollars spent, but the trends over time. The below graphic shows one view of the data, as dollars spent increase across all payment models, but does not show the changing position of the various models. 

 

CMS Innovation Center Goals  Dictate Value-Based Care Payments Increasing

 

The CMS Innovation Center has stated that the goals of their strategic direction are that:

 

  • All Medicare fee-for-service beneficiaries will be in a care relationship with accountability for quality and total cost of care by 2030.
  • The vast majority of Medicaid beneficiaries will be in a care relationship with accountability for quality and total cost of care by 2030.

 

While the 2030 goal appears ambitious, the trend-lines are trending in that direction. Not only is Value-Based Care increasing as a total percentage of all payments, but specifically categories 3 & 4 are increasing against category 2. The movement is both away from Fee-For-Service and moving toward full risk models.

HCPLAN Annual Reports Demonstrate Increasing Value-Based Care Payments

 

Below, we have linked all the HCPLAN data from previous year’s studies, with links to their interactive reports. The data is clearly pointing to Value-Based Care payments increasing, year-over-year.

 

 

2015 HCPLAN Value-Based Care Payments Increasing 2016 HCPLAN Demonstrates Value-Based Care Payments Increasing
2017 HCPLAN APM Demonstrates Value-Based Care Payments Increasing 2018 HCPLAN APM Demonstrates Value-Based Care Payments Increasing