Helping Your Providers Make the Transition to Value-Based

Care

6 October 2021 – NCMGMAR.W. “Chip” Watkins, MD, MPH, FAAFP

Your Speaker R.W. “Chip” Watkins, MD, MPH, FAAFP

Regional Medical Director for Community Care of NC, Regions 1,2,3

First MD in US to become an NCQA PCMH CCE

Former member of NCQA’s Physician Advisory Committee

Member of MINT – Motivational Interviewing Network of Trainers

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They Can Run, But They Can’t Hide Across all lines of business, health plans are under immense pressure to

control costs and improve quality.

Purchasers – whether employers, states, or the federal government –are demanding payment reform, lower costs, and better outcomes.

The US Department of Health and Human Services (HHS) and US Centers for Medicare and Medicaid Services (CMS) have set clear goals and a timeline for shifting Medicare reimbursements from volume to value and are testing new models through various payment reform initiatives.

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Success with Value-Based Care

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QUALITY x OUTCOMES

COSTVALUE =

EXPERIENCE EXPERIENCEPATIENT PROVIDERx x

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Success with Value Based Care

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“Effective models include 4 foundational principles:

strategic contracts accurate coding and documentation optimal star ratings for MA products exceptional care management.”

- Health Leaders Media

This is where practices need their physicians/providers to step up!

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Time Keeps On Slippin’, Slippin’ Into the Future

As ACOs/CINs take on more at-risk contracts in the value-based payment era, it is increasingly important that CINs and their members understand how the health status of contracted populations is calculated in their contracts.

Appropriately documenting and coding a patient’s full illness burden is essential to the financial health of both practices and CINs.

Medicare and Medicare Advantage plans use HCCs (hierarchical condition categories) to quantify the illness burden of each patient and to estimate the annual cost of providing care for that patient.

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Predicting Cost of Care and Stratifying Risk: HCCs

HCCs are weighted using a risk adjustment factor (RAF) based on the complexity of the patient’s disease, along with demographic factors such as age, gender, and patient domicile (living at home or a skilled nursing facility, for example).

These RAF scores, similar in theory to a DRG relative weight, are calculated annually based on 12 months of documented diagnostic coding history.

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Financial Impact of Under-Coding

When patient conditions do not make it into the EHR, whether due to poor clinical documentation or more than a 12-month gap between patient encounters, the financial impact can be disastrous.

If the provider fails to document HCCs or coexisting disease conditions, the RAF score will be lower than it should be, resulting in lower capitated payments.

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This is Depressing!

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Contracts

COVID-19

Coding

Staffing

Debt

Payroll

EHR Issues

Loss of Autonomy

Burnout!!

The Loss of Autonomy Can Be PainfulSome long for “The Old Days”

This is true, particularly for Independent providers

Feel like they have no choice to do VBC – back against the wall

Feel they have to have an EHR system to meet the insurance company’s needs

Feel like they are working for the insurance companies

Takes leadership and courage to have these conversations with docs/providers in your practice

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Guiding Your Providers toward Success

1. Get to know what motivates them

a) What are their dreams for the practice?

b) What are their dreams for themselves?

c) Where do they want to be in 3 years? 5 years? 10 years?

d) What is the most important thing they want from the practice?

e) What is the most important thing they bring to the practice?

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Guiding Your Providers toward Success2. Help them focus on value-based care

a) If they are going to get where they want to go, what changes need to occur at the practice?

b) Why might they want to add these kinds of contracts?

c) What are some of the good things about VBC and what are some of the not-so good things?

d) What kinds of tools and support are needed to make the changes?

e) What has occurred in the past that gives them confidence in their plans for the future?

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Guiding Your Providers toward Success3. Elicit from them their motivations for change

a) How important is it, if at all, for the practice to adopt VBC?

b) What are the 3 best reasons for adopting VBC?

c) What are the worst things that might happen if you don't make this change? What are the best things that might happen if you do make this change?

d) If the practice does decide to adopt VBC, how might you go about it, in order to succeed?

e) If the practice was 100% successful in making the changes we are talking about, what would be different?

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Guiding Your Providers toward Success4. Negotiate a Plan of Action

a) When you feel you’ve listened enough and all sides of the discussion have occurred, “Shift” into planning by asking Key Questions:

“What do you think you (we’ll) will do?”

“What are you thinking at this point?”

“What changes, if any, are you thinking about making?”

a) Planning often continues with the need to reassess to modify or adjust.

b) Sometimes the providers may abandon the plan all together and you may need to return to evoking (last slide)

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Helping Your Providers Make the Transition to Value-Based

Care

6 October 2021 – NCMGMAR.W. “Chip” Watkins, MD, MPH, FAAFP