Maximizing value-based care

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Jan 23, 2017

The transition to value-based care (VBC) can be tricky. Success depends on organizational stakeholders’ ability to collaborate to reach the goals set for them. Despite the Department of Health & Human Services’ (HHS) aim to convert 30 percent of fee-for-service (FFS) Medicare payments to value-based payment models by the end of 2016 only one third of physicians believe the healthcare system should transition to value-based care.


There’s clearly still a sense of skepticism when it comes to making this transition. The opportunities that VBC models bring, however, offer benefits that are worth exploiting. Let’s look at some ways providers can work to maximize value based care:

1. Find revenue leaks: According to Marc Lion, CEO of Lion & Company CPAs, the average practice has a 10-15 percent profit leak. While these leaks can be the result of several factors, a major one is debt management. Reducing bad debt by just two percent can deliver tens of thousands of dollars to the bottom line of practices.


Payment methods can also make a difference. Almost 85 percent of providers preferred to receive payer payments through electronic funds transfer or electronic remittance advice, even though 89 percent had received paper checks and explanation of payments from one or more of their payers. With increasing patient responsibility, healthcare organizations must work to optimally manage revenue cycles with a view to gaining more input from consumers. Additionally, they can reduce bad debt management by:

  • Helping patients get insured and reducing self-pay patients.
  • Streamlining patient financial clearance to accurately understand and explain benefits to patients before delivery of care.
  • Maximize reimbursement for each episode of care by making sure payers meet negotiated, contracted reimbursement rates.
  • Efficiently collect payments.

Besides focusing on consumers, organizations must ensure physician alignment with organizational revenue goals. Research estimates suggest that as many as 25 to 35 percent of patient cases referred from employed providers are going to specialists and facilities affiliated with another health system. This amounts to as much as $40 million in lost revenue per year. Organizations must take advantage of progressive tools to assist with the clinical and economic integration of physicians within healthcare systems.

2. Embrace claims data: For accurate and timely processing of claims, providers need customized solutions depending on whether it’s a FFS or VBC model. According to MGMA, the average medical practice has between 20 to 35 percent of their claims rejected. Moreover, 31 percent of providers still use manual claims denial management. The American Medical Association found that medical practices spend almost $15,000 on the phone calls, investigative work, and claims appeals associated with reworking claims. Medical practices should still be familiar with the general landscape of Medicare standards and the other payers. Be sure to access newsletters, webinars and conferences to improve their own knowledge base. Also consider the following tips:

  • Provide periodic staff training to ensure they know what is expected of them
  • Establish standard policies to make sure nothing is missed
  • Ensure constant checking and rechecking to avoid reworking

3. Capture reporting data in a timely manner: Regulatory and compliance requirements, combined with a lack of standardization and interoperability between different stakeholders sharing the same information, make effective use of data difficult. Developing a better understanding of medical outcomes requires analysis of a complex cause and effect loop. In fact, one-third of employers expect the greatest cost increase from ACA implementation to take place in 2016, as new reporting, disclosure and notification requirements take effect. Organizations can work to prepare themselves to adapt to these requirements by:

  • Simplifying data preparation for exploratory analytics which makes data useful more quickly and easily than traditional solutions
  • Increasing productivity by reducing time required to sieve data and facilitate better utilization
  • Bringing data directly to analysts reducing the workload on the internal IT infrastructure
  • Improving organizational data usage

4. Manage risk: The only way to successfully move forward in the VBC era is to support it. Identify care models and alternative payment opportunities, gain executive buy-in, build relationships among providers, and manage financial risk and utilization to fuel the transformation required to provide value-based care. Changes in benchmark methodology mean healthcare organizations should work on designing underlying initiatives that focus on quality at a lower cost. Having well-established quality metrics in place will help to have appropriate protection mechanisms for patients who are the vulnerable stakeholders.

5. Improve patient retention: Patient retention is vital—organizations must keep the following factors in mind for the retention process.

  • Price transparency is considered one of the ways to stabilize health care cost. However, transparency is not possible without a system to collect, organize and present price reporting to employers and employees.
  • Greater patient interaction helps measure patient satisfaction and stresses on the need to increase consumerism in healthcare. Smart healthcare providers will do everything in their power to secure patient satisfaction. Embrace the emergence of omni-channel interactions to improve workflows and deliver a more positive patient experience.
  • Comparative performance measures data can help reveal important and relevant information. Physician leadership can help physicians be the champions of the performance assessment component of program by making sure physician can dig deep into the data, develop confidence in its findings and understand what precisely needs to change.

6. Position care team: Get the right data to the right people at the right time, so healthcare staff can focus on their specific jobs. This also allows care coordinators to help their patients navigate the system to close care gaps, and help highly trained clinical staff focus on the sickest, most complex cases. By acknowledging the aspects of collaboration inherent in healthcare and striving to improve systems and skills, identifying best practices in interdisciplinary team-based care holds the potential to address some of these dangers, and might help to control costs.

About the author

Mason Beard

Mason Beard, 
Chief Solutions Officer, Philips PHM

Mason Beard is Chief Solutions Officer for Philips PHM. He leads the strategic and operational development and programs of the Philips Population Health Management group. He is the co-founder of Philips Wellcentive and has deep experience in developing flagship healthcare IT innovations.

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