Transitioning from Fee-for-Service to Value-Based Care: How to Manage Your Revenue

It’s no secret that the shift to value-based is leading more physicians and nurses to be employed by hospitals. Patients feel the height of these effects because Medicare reimbursement rates have not yet kept pace with inflation. So how can physicians and nursing facilities manage their bottom line while losing money caring for this growing group of patients? Some will simply take care of fewer patients, which will reduce overall revenue in an effort to minimize the financial impact. However, there are things doctors and nurses can do to balance out the loss and actually improve margins during the slow transition to value-based care.


Overcome the Obstacles

First things first, you’ll need the right infrastructure and tools to make sure you’re accurately tracking all patients, so you can measure your performance and revenue. While this happens annually or quarterly, hospital CEOs and CFOs should be regularly accessing and evaluating this data in order to make continuous adjustments. Once you’ve synthesized all this information, you’ll want to rethink your traditional KPI’s (key performance indicators) associated with fee-for-service. Rather than focusing on traditional, one-dimensional metrics like headcount in beds or number of surgeries, you’ll need to get the full picture of your quality metrics. Instead, focus on metrics like:

  • Cost per case
  • Readmission rates
  • Length of stay
  • Complication rates

When you dive deeper into the data, you will probably find there are plenty of areas you can improve. Are there specific diagnoses codes that you struggle with? Are there other factors that contribute to readmission rates that might not be happening at your hospital?


Improve Care Coordination

Readmission rates are a major metric that is evaluated by CMS. However, even if you provide the best care, a patient could still be readmitted because they aren’t following up with their primary care provider. Skilled nursing facilities and home health solutions are also important factors to evaluate the quality of a patient’s care after they leave your hospital. Choosing the right partners and holding them to a high standard will help lessen readmissions and provide better continuity of care.


Become More Efficient

In come cases, you might find that the length-of-stay is longer for patients that receive an MRI, for example. If you only have one MRI for both inpatients and outpatients, your teams may be prioritizing outpatient diagnostic tests simply to accommodate business hours. But that leaves inpatients to wait until evening (around 8 pm) to get their MRI, which increases overall length-of-stay.


Other Strategies to Optimize


1. Expand access points

Free-standing ERs; outpatient diagnostic centers and urgent care facilities can all increase your volume of services you provide without the additional costs and potential penalties from inpatient stays.


2. Telehealth technology

Physicians or nurses that travel between hospitals, practice offices, and outreach. Clinics can reduce travel time and see more patients through virtual visits. Offering convenient telemedicine services can also be a market differentiator and attract more patients with commercial insurance that prefer the convenience of virtual visits.


3. Focus on specialization

By developing signature services you can focus on recruiting top-notch physicians and creating centers of excellence. Especially for procedures like joint replacement and bariatric surgery, you will draw patients that are potentially willing to pay more for a unique, high-quality experience. Ultimately, all of these efforts will result in better access to high-quality care for your patients, which will improve your composite scores and increase reimbursement potential.


Understanding Population Health: Why It’s a Reflection of Your Patients

Improving population health begins with focusing on the health of each one of your patients. To do so, we in the healthcare community—nurses and physicians alike, need to identify and engage patients—particularly those of high risk—throughout the continuum of care. These are individuals most likely to be readmitted, miss an appointment, skip medications or unable to pay their bill.


But how can we pinpoint these individuals efficiently when we’re often looking at multiple databases and EHRs, examining enormous quantities of unstructured data—from multiple notes fields and categories, pathology reports, radiology notes, to admission notes and everything in between—containing invaluable historical information, all entered at different times, in different ways by different people?


Standard EHR systems do not currently provide a way to easily synthesize and summarize patient information on the changing risk factors recorded in different EHRs to support clinical decision-making. In addition, EHRs do not capture all the data points to understand the risks patients face, nor does it prioritize care for those at high risk for readmissions or infections. Imagine then how much we could do to identify, treat and engage patients if we had a way to analyze unstructured data!


The primary benefit of normalizing and aggregating unstructured data is attaining a cohesive picture of the patient’s history, diagnosis, treatment, and outcome. If details around the pathology of a patient’s tumor are only recorded within the pathology note for example, then analysis cannot include such things as genomics, margin reports, laterality, size, shape or even perhaps the stage of the tumor. Including that information along with trends for an individual patient or an entire population could be valuable. Additionally, combining that information with data about the treatment and outcome of a patient—which is possibly available within textual notes fields—can provide a rich field for research and results-driven treatment.


Here at CareSkore, we thrive to compile—and where applicable—translate data from hospitals electronically. Through our Personalized Population Management™ platform, we’re able to identify patients at high risk of readmission and hospitalization by combining clinical and 3rd party data. We put in place standard care plans so everyone on the team knows the steps they should be taking to manage the patients. CareSkore also allows our partners to reach out to patients even after they have left the nursing facility, using our Iris module, and document the follow-up care to provide them resources as needed.


Fundamentally, integrated care management, leveraged by data and predictive analytics, helps nursing home administrators to:

  1. Identify and engage patient populations at-risk for poor outcomes or unnecessary intervention at a time of need and opportunity for impact
  2. Perform assessments and respond to changes in patients’ conditions to uncover problems that, if addressed through effective interventions, will improve care and reduce the need for expensive services—particularly ER visits and hospitalizations
  3. Collaborate with patients and their caregivers as well as primary care, specialty, behavioral health, and social service providers and show hospital partners they can perform proper follow-up care
  4. Have an integrated system that provides a complete picture of expenditures and combines risk prediction software, chronic disease criteria, or utilization thresholds with patient-to-provider referrals or assessments
  5. Combines the strengths of both quantitative and qualitative approaches and brings data together from multiple sources


All in all, benefits extend beyond medical issues to address, to the extent possible, how patients’ psychosocial circumstances affect their ability to follow treatment recommendations and achieve a healthy lifestyle. The goals are to maintain or improve patients’ functional status, increase their capacity to self-manage their condition, eliminate unnecessary clinical testing, and reduce the need for acute care services.


The result? Fewer nursing visits, shorter hospital stays, better intra-office communication, faster and efficient communication between primary physician and nursing facilities, and cost savings that could pay for the expansion of EMR use in those facilities.


This post is an edited version originally published on McKnights.


Join Us at The Value Based Health Care Congress 2016

Untitled design

The Value-Based Health Care Congress is just a week away and we’re excited to announce we’ll be there, standing alongside industry veterans and learning more about the state of value-based care. Under The Value-Based Health Care Congress are 3 individual tracks for providers, each covering some of the key pillars of the landscape today:

  1. The MACRA Strategy Collaborative Summit
  1. Value-Based Network and Contract Management Summit
  1. ACO Strategy Summit

We went ahead and listed some of the conference sessions around care quality and health care IT that we’ll be looking forward to attending, and hopefully you will too. Be sure to stop by the CareSkore booth in the exhibit hall to see our Personalized Population Management™ platform, and learn how your healthcare organization can improve both clinical and financial outcomes. Without further ado, here are some of the sessions that we’re excited to see (exact times subject to change):


1. Measuring for Value – Panel Discussion

Track and Time: Main Summit, Day 1 @2:05pm

Core quality measure sets are in place and we’ve taken a significant leap forward in providing accurate, useful information on healthcare quality that can inform decisions. The next step in this transition to value-based care rests on our ability to integrate quality and resource use performance to ultimately drive better outcomes.

  • Understand the quality-spending relationship and how it promotes provider buy-in and success in risk-based contracts
  • Learn how to incorporate the patient voice to develop meaningful measures
  • Align measures across the continuum of care to reduce burden and improve efficiency


David Introcaso (@HealthcareIssue)

Helen R. Burstin (@HelenBurstin) – Sr VP, Performance Measures at National Quality Forum

Kate Goodrich – Director, Center for Clinical Standards and Quality at CMS

John S. O’Shea – Sr Fellow, Center for Health Policy Studies at The Heritage Foundation

Stephen L. Ondra (@StephenOndra) – Chief Strategy Officer at Amida Technology Solutions

Linda Walker – VP, Health Security at AARP


2. Examine the Role of Health IT in Delivery System Transformation

Track and Time: MACRA Summit, Day 2 @10:45am

Healthcare IT is undoubtedly a critical piece to how we advance quality and value. ONC’s Elise Anthony gives us the catch-all on healthcare technologies—from flow of health info to patient data access, and care delivery—required for participating in CMS programs.

  • Understand how health IT is the foundation to better care, smarter, spending and healthier people
  • Learn about new health IT initiatives that can support practical needs of patients and providers


Elise Sweetney Anthony (@Policy2Progress) – Director, Office of Policy at ONC


3. Explore the Ingredients of a Health IT Value Strategy

Track and Time: MACRA Summit, Day 2 @11:30am

Implementing health IT does not guarantee success. These technologies—focused on improving care must allow stakeholders to be able to find usability and usefulness that also support processes—both business and clinical—of a value-based reimbursement system.

  • Review the HIMSS STEPS™ model and its five components
  • Identify areas where health IT has proven value and non-technical barriers to IT optimization
  • Explore potential new functions of health IT that should support value-based care


Peter Basch – Medical Director, Ambulatory EHR and Health IT Policy at MedStar Health

Patricia Wise – VP, Health Information Systems, HIMSS


4. Engage Physicians in ACO and Other Value-Based Models to improve Quality

Track and Time: ACO Summit, Day 2 @2:15pm

Successfully engaging physicians ensures that ACOs and other value-based endeavors reach potential, but that is easier said than done. It’s especially challenging when physicians continue to receive fee-for-service and value-based payments simultaneously.

  • Understand physicians’ risk-based payment and MACRA, and how to transition to a value-based mix
  • How to coordinate for optimal management of complex patients
  • Utilize integrated and actionable claims data, not multiple EHRs, and learn how to report data that demonstrates the impact of clinical decisions


Abigail Chen – Medical Director, Quality and Clinical Integration at Mount Sinai


5. Achieve Better Quality, Less Effort, and Greater Savings – How You Can Have All Three

Track and Time: ACO Summit, Day 2 @3:00pm

Through organizing information and communicating it with providers in addition to focusing on specific efforts such as cardiac and respiratory conditions, providers can improve cost and quality metrics in parallel and demonstrate the value throughout the health care community.

  • Explore feasibility of collecting and tracking patient data to understand quality performance
  • How cutting costs and increasing quality scores can earn shared savings
  • Illustrate examples of payer-provider engagement and alignment around shared objectives


John Haughton (@haughton_md) – CIO at Chautauqua AMP; CQO at Independent Health Plan