The passage of the Medicare Access and CHIP Re-authorization Act of 2015 (MACRA) was intended to replace fee-for-service (FFS) with a framework that rewards providers for better outcomes and improved quality of care of population health while containing per capita costs. This shift places more emphasis on the entire care community’s coordinated efforts in sharing in both risks as well as responsibilities of the costs and outcomes. Although the impact of the law is currently focused on Medicare, its framework and delivery incentives are increasingly becoming the new model for other payers – and in the process, turning the health care delivery and reimbursement systems on their heads.

Value-based care (VBC) or “outcome-based care” is the latest of many changes to emerge in recent years from CMS, and is quickly being adopted by other payers as it begins to replace the traditional FFS reimbursement model. One trait that too many healthcare providers share is resistance to change. (Remember how many balked at the switch to EHR and later, the introduction to ICD-10 codes?) Practices not already on board will need to get ready by adopting a proactive mindset. Those practices which continue to lag behind will likely see reductions in reimbursement as they struggle to catch up with the rest of their peers.

The Health Care Transformation Task Force reported that by the end of 2015 41 percent of its members were participating in value-based reimbursement arrangements, as value-based payer contracts are emerging as the standard of health care, gradually replacing fee-for-service. Payments are now directly tied in to the level of quality care provided, instead of the quantity of services. Here are several key areas that can help providers and their organizations cut spending while improving margins for revenue. As you will see, the increased use of healthcare analytics will play a crucial role in meeting these VBC objectives.

The effects of Value-Based Care and Analytics: 

• Help track and control costs – understanding their expenses is critical for any organization if they intend to improve profitability by reducing unnecessary spending.
• Improve reporting on quality measures – establish one standard of quality measures for consistent and accurate reporting
• Provide a better experience for patients – working to keep patients engaged in their own care through follow-ups and prescription usage is one of the key components of value-based care
• Improve long-term value for patients – creating a trusting environment for patients by leveraging analytics to gain insights for improved outcomes.
• Maximize staff resources – allocation of staff, such as scheduling nurses for optimum times, is improved during VBC transition

In particular, specialists treating chronic diseases, such as cancer or chronic heart disease should benefit from analytics’ improved care coordination as they become more financially-responsible for the holistic care of patients. Implementing care programs based on the collection and analysis of relevant data may reduce unnecessary re-admissions and visits to the emergency room.

Thriving with VBC payments – what practices need to do:

• Your practice will require a holistic view of aggregate patient data
• Collect data from multiple sources: EHR, adjudicated claims, HIEs, sociodemographic information
• Analyze the collected data
• Gather insights from all involved team members to decide which actions to take moving forward.
• Promote engaged patients
• Effective patient care now means having the ability to offer coordinated and automated as well as personalized outreach to patients, while remaining within their comfort zones.
• Improve coordinated care among your team as a result of accurate data, team input and patient engagement
• Under value-based reimbursement, your team shares a larger risk for patient outcomes. Interoperability between systems is critical to effective collaboration for care continuum, with a platform that is both fast and secure.

A new era: analytics in payment models vs care models

To successfully utilize any analytics program, there should be the means to gather all relevant information and develop an actionable plan, with insights based on the organization’s top priorities. Up until the passage of MACRA, the emphasis was on streamlining and refining reimbursement model with the advent of EHR, with fee-for-service a main priority. Now, the focus is changing to care delivery itself, with reimbursement models falling into line behind the CMS mandates.

Healthcare analytics are best utilized when they can combine seemingly-disparate sources of data into a comprehensive and uniform solution to provide a clearer picture into a practice or organization’s operational, clinical and financial areas.  An advanced system of analytics can increase understanding of quality measures in payer contracts and in reporting the mandated supporting data to government and commercial payers.   

Integrating VBC/ reimbursement plans into your revenue cycle:

• Develop a strategic, financial plan, including new risk models, to guide the practice or organization through the changes of the shift to VBC.
• Learn and implement new care models based on outcome while releasing the “quantity mindset.”
• Be proactive in embracing the new reimbursement and care delivery model become proficient in using data analysis.
• Increase practice capabilities to achieve improved population health outcomes.
• Technology and analytics, when utilized successfully, can help reduce the risks of losing market share and reduced relevance.

Partner with an experienced claims analysis and management organization

Working in partnership with an experienced claims billing and management service can help you and your staff understand the latest reimbursement developments from CMS and other payers. Compliance is critical, yet there are more variables than ever to track, report and analyze; large organizations may have the staff and financial resources to acquire and upgrade to the latest, most sophisticated systems, but smaller practices may find the challenges too daunting to be readily implemented without assistance.

M-Scribe can help analyze your practice’s strengths and weaknesses, where you may be losing revenue and how to meet the new VBC reimbursement guidelines while making the most of your claims management dollars. Contact them at 888-727-4234 or email for a free, confidential analysis and learn how they can save your practice money and time while keeping you compliant and integrated.

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