Navigating Risk Management for Practice Groups in Value-Based Care

Participating in value-based care (VBC) contracts can require significant changes for practice groups. Unlike fee-for-service (FFS), where physicians are paid for each service, reimbursement in VBC involves a level of financial risk because it is determined by the quality of care provided and the effective management of costs.

With the Centers for Medicare and Medicaid Services (CMS) goal to have 100% of Medicare beneficiaries in a value-based arrangement by 2030, practice groups caring for Medicare populations need to be prepared to successfully manage risk in VBC contracts. No matter where your practice group is on the VBC journey, having a solution that includes robust data analytics and reporting to monitor and manage risk is critical to enable the transition from FFS to VBC.

Understanding Risk Levels in Value-Based Care

In VBC, there are two types of risk: upside-only and upside/downside or two-sided risk. In upside-only arrangements, providers share in the financial savings generated from improving patient outcomes while reducing the cost of care. In two-sided risk, providers share in both the savings and the losses. This means not only do they not receive additional revenue for unrealized savings, but they must pay a percentage of any losses.  

The VBC journey is marked by incentive programs and three established alternative payment models (APMs):

1. Quality Incentives — organizations receive pay-for-performance (P4P) and/or pay-for-quality (P4Q)-based reimbursement through the Merit-based Incentive Payment System (MIPS).
2. Bundled payment models — designed to reduce unnecessary costs and improve the quality of care, these models allow specialists who engage in these arrangements to receive payment for all services involved in a specified episode of care, e.g. knee replacement. It also requires specialists to manage the costs appropriately to realize savings.
3. Medicare Shared Savings Program (MSSP) — this model allows accountable care organizations (ACOs) to share in the savings they generate if they meet certain quality and cost benchmarks. They also share in the losses resulting from not managing costs effectively; this is where two-sided risk comes in. With ACOS delivering care to nearly 50% of those enrolled in traditional Medicare, this program aims to promote coordinated care, reduce unnecessary hospitalizations, and enhance overall patient outcomes.
4. Full capitation — also called delegated risk, these arrangements involve providers receiving 100% of the premium reimbursement dollars while also holding 100% of the responsibility for managing the cost of care.

Advancing Value-Based Care Initiatives With Confidence

Before entering into risk-based contracts or increasing your level of risk, it’s crucial to assess your group’s readiness and capabilities. VBC represents not only a shift in how physicians deliver care but also the ability to use their data to effectively track and report on their quality measures. This foundation helps ensure you’re making data-driven decisions, which is essential for success in VBC. To navigate the levels of risk in VBC, your practice group will need to be prepared to:

1. Level Up Your Data and Reporting Capabilities
In a system where reimbursement is linked to the ability to meet or exceed benchmarks, having effective data and reporting platforms will be key. For practice groups, improving patient outcomes will be driven by the ability to access and respond to actionable, timely data. Tracking quality measures in real time will help drive effective capture of VBC incentives. Use reports to monitor quality measures, including those related to readmission rates, timely care coordination, and patient safety, among others.

2. Ensure Delivery of the Standard of Care
Informed clinical decisions bolster the delivery of VBC and also support the execution of the standard of care. To support providers in delivering evidence-based care, clinical decision support (CDS) tools are key for both enabling evidence-based medicine and simultaneously meeting the VBC goal of improving the quality of care delivery. Implement data-driven interventions to address any identified issues and optimize patient care.

3. Enhance Care Coordination and Collaboration
Seamless communication and information sharing among healthcare providers is vital for VBC success. Invest in technologies and processes that facilitate care coordination. Consider emphasizing technology that is certified by the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC). ONC-certified health IT supports interoperability, which is crucial for effective care coordination.

Choosing a single, integrated platform solution can enhance documentation quality, speed, and accuracy and foster improved care collaboration. This enables the ability to track patient encounters in real time, identify high-risk patients, and share care plans with the broader care team, as well as helping to support effective communication with extended care partners.

4. Prioritize Patient Engagement
Engaging patients in their care is a part of the quintuple aim and a cornerstone of VBC. Implement strategies to involve patients in their care. This includes educating them about their conditions, encouraging treatment plan adherence, and offering self-management tools. Empowering patients can improve satisfaction and lead to better outcomes.

Consider using patient portals, telehealth services, and mobile apps to enhance patient engagement and communication. Regularly gather patient feedback to identify areas for improvement and to ensure that they feel supported and informed.

5. Leverage Data Analytics
Utilizing data analytics is essential for managing risk in VBC. Look for an analytics solution that supports the timely identification of high-risk patients, tracks performance metrics, and provides insights into care patterns. Automated workflows and real-time alerts enable faster documentation, improve clinical decision-making, and return valuable time to high-quality patient care. Regularly review analytics dashboards to identify areas for improvement and to ensure that your practice is meeting its VBC goals.

The Role of Technology in Managing VBC and Risk

Effectively engaging in VBC arrangements requires robust data and insights, not just within your own practice group but throughout the entire patient journey. By leveraging technology solutions to improve communication and decision making with care partners across the continuum, you can enhance provider alignment and increase the quality of care.

The right technology solution, such as an ONC-certified electronic health record (EHR), can support the standard of care, improve visibility and care collaboration, and offer a seamless exchange of data between all care providers via an interoperable platform. At PointClickCare, we’re committed to guiding you through this evolving healthcare landscape with tips, best practices, and solutions that address common challenges and improve outcomes for our customers.