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BridgepointMD Blog, January 2025

3 Essential Strategies for Specialists Navigating the Shift to Value-Based Care in 2025
 
While value-based care (VBC) models have focused on primary care for the last decade or more, regulators and market leaders have signaled that in 2025 the spotlight will shift to specialty care. In conversations we’ve had across the country, three reasons specialists avoid value-based contracts emerged: lack of experience, misaligned incentives, and fear of lower reimbursement.
 
For specialists new to VBC, there's still the option to mainly engage in fee-for-service (FFS) contracts while gradually transitioning to a more value-focused approach to care delivery. Specialty physicians have historically concentrated on managing specific conditions relevant to their expertise. However, there is a growing recognition of the importance of encompassing a patient’s comprehensive health profile while striving for accurate documentation and prioritizing patient and quality improvement initiatives.

In this blog, we'll delve into how specialty physicians can enhance patient outcomes and unlock revenue opportunities by focusing on patient navigation, accurate coding and documentation, and quality improvement initiatives in their practices.
 
     1. Patient Navigation: Opportunities to Drive Patient Engagement & Close Care Gaps
 
To better address the needs of polymorbid patients, specialty practices may benefit from incorporating patient navigation services that extend beyond traditional medical care. These services should emphasize promoting patient compliance with care plans and capturing essential metrics, such as preventative services and identification of care gaps. Successful capture of these measures not only helps in coordinating care but also enables the practice to bill for care navigation services through FFS-based Chronic Care Management (CCM) codes, applicable to Medicare and MA beneficiaries. CCM codes cover activities that do not typically occur during a face-to-face encounter, such as telephonic symptom discussions, reviewing medical records and test results, providing self-management education and support, and facilitating the exchange of health information with other healthcare professionals. By integrating these services, specialty practices can enhance care coordination and qualify for additional reimbursement, aligning with VBC objectives.
 
Previously limited to primary care, regulatory changes have enabled specialists to provide proactive care navigation, including tasks like arranging transportation and promoting medication adherence. Many specialists have yet to fully utilize these opportunities, which can offer both clinical and financial benefits.
 
Core Benefits of CCM for Specialists

  • Improved Patient Care and Quality

    • Increase patient engagement and adherence to treatment plans through regular check-ins.

    • Identify and address gaps in care early, preventing complications and improving health outcomes.

    • Manage external social factors (e.g., housing insecurity, food access, transportation) that impact patient health.

    • Uncover quality gaps that can contribute to better performance in quality incentive programs.

 

  • Additional Revenue

    • Earn an additional per-patient-per-month (PMPM) revenue for proactive care navigation for eligible patients. The reimbursed amount may vary depending on geography, practice type, patient complexity, and payer agreement terms.

    • This new recurring revenue stream is in addition to existing Medicare and MA reimbursements for providing care and can be coupled with other care navigation services including principal care management (PCM), transitional care management (TCM), and remote patient monitoring (RPM).

 

  • Better Clinical Decision-Making

    • Gain a comprehensive understanding of patients’ medical complexities, leading to better informed, patient-centered treatment plans.

    • Consideration of social determinants of health when determining approach to treatment and patient care improvements.

 
By implementing care navigation services and leveraging CCM codes, specialists may enhance patient care by addressing clinical and non-clinical needs and improve revenue.
 
     2. Accurate Coding and Documentation: Better Patient Management and Appropriate Reimbursement for the Care You   Provide
 
While care navigation is a new avenue for some specialists, there’s also the ongoing challenge of reimbursement associated with the care they’re already providing. This requires accurate coding and documentation of all conditions and services rendered, including conditions outside of the specialist’s immediate focus.
 
Some specialists may hesitate to document conditions that are unrelated to their specialty.  Others may be concerned about ‘upcoding,’ or intentionally inaccurate billing to inflate reimbursement. The reality is that accurate documentation of all presented conditions through hierarchical condition category (HCC) codes informs the payer of patient complexity and is used as a risk adjustment model to predict a patient’s healthcare costs and can affect reimbursements. Furthermore, initiatives to improve coding and documentation are the basis to collect data that can then uncover opportunities to identify gaps in care and/or improve care delivery.  

Common Documentation Issues:
 

  • Missed Chronic Conditions or Inappropriate Coding: Specialists often underreport conditions like diabetes or hypertension that may not seem directly related to their specialty. By documenting these conditions using HCC codes, they create a fuller picture of the patient's health and potentially impact reimbursement. Once in value-based payer arrangements, HCCs are used to determine capitation amounts based on patient complexity and risk-adjustment. Accurate coding and documentation will also supply necessary support for level 3-5 services, potentially minimizing the occurrence of payer audits.

 

  • Annual Coding and Re-Coding: A common example of missed opportunities to document disease severity is physicians being required to document a patient's foot amputation every year. If they fail to document it in one year, the payer does not account how the amputation contributes to the patients’ overall clinical complexity which could result in lower reimbursement. It's a quirky but essential reminder that accurate and continuous documentation is critical, and sometimes redundant from year to year.

 

  • Incomplete Procedural Notes: Inadequate documentation of procedures or interventions, such as imaging studies or biopsies, can result in missed reimbursement opportunities. A dedicated focus on thorough and detailed procedural notes can highlight the value and scope of care provided, reinforcing accurate reimbursement.

 
Accurate and complete documentation and coding is a fundamental administrative function for all practices and can improve performance in both fee-for-service and value-based payer contracts. These initiatives also create opportunities to better capture care delivery data, which can in turn be used for quality improvement initiatives and payer contracting conversations.
 
     3. Quality Improvement: Using Data to Drive Performance
 
Dedicating time and precious resources to quality improvement initiatives drives better patient outcomes and could also create supplemental reimbursement in existing contracts. Quality measures, sometimes included in payer contracts, are used to assess the effectiveness of the care provided, and physicians who meet or exceed benchmarks in these measures can receive bonuses or other incentives, depending on the contract.
 
Essential Elements of Quality Improvement for Specialists:
 

  • MIPS to MVP Transition: For providers participating in Medicare, there's a shift from the well-known, albeit unpopular Merit-based Incentive Payment System (MIPS) to the newer MIPS Value Pathways (MVP) program. MVP allows specialists to focus on specific measures in their area of expertise, with the intention of making it easier to report on quality performance on measures that are relevant to their practice. Another new aspect of the MVP program is assessing cost performance. Providers who perform well on these measures may receive larger bonuses, based on how they compare to their peers annually.

 

  • Quality Clauses with Commercial Payers: Many commercial insurance contracts contain quality clauses or ‘quality gates’ that require providers to meet specific thresholds for each quality measure. If a provider fails to meet those benchmarks, they may not earn performance bonuses. Thus, monitoring and improving performance on quality metrics is crucial, as even missing a few cases can lead to significant financial losses.

 

  • Data-Driven Negotiations: A robust focus on quality improvement initiatives and the accompanying data collection process allows physicians to bridge data asymmetry gaps with payers by leveraging their valuable performance data to negotiate favorable, achievable contract terms based on their historic performance. If providers consistently meet quality measures, they are in a stronger position to negotiate improved reimbursement rates, quality bonuses, and eventually shift to sub-capitation or capitation. Providers can bolster their confidence in meeting or exceeding performance benchmarks through ongoing evaluation of their quality performance.

 
Specialists have promising opportunities to transition to value-focused care delivery and prepare for alternative payment models by gradually optimizing workflows and reimbursement strategies. Approaches like providing care navigation services, concentrating on precise documentation, and prioritizing quality initiatives can help specialists enhance patient outcomes, increase practice revenue, and secure a sustainable future in healthcare.
 
Key Takeaways:
 

  • Improve patient outcomes and better inform care delivery, coupled with the creation of new revenue streams, by offering care navigation services reimbursed by CCM codes.

 

  • Prioritize accurate and complete documentation to capture patient complexity, securing appropriate reimbursement, and minimizing the potential for claims/service audits.

 

  • Embrace quality initiatives to improve patient outcomes, perform in payer contracts, and strengthen financial performance.

 
By implementing these essential strategies, specialists can begin to confidently adapt to value-based care and drive long-term financial success.
 
BridgepointMD partners with specialists to help them improve performance in fee-for-service contracts and to prepare for alternative payment models, leveraging strategies to reduce cost of care and improve patient outcomes. We’d love to connect to discuss your practices’ opportunity. Please contact us at info@bridgepointmd.com.   
 
Reference:
[1] Centers for Medicare & Medicaid Services, Chronic Care Management (CCM) Services: Overview and Resources. [Online]. Available: https://www.cms.gov/about-cms/agency-information/omh/downloads/ccm-toolkit-updated-combined-508.pdf

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