Over the course of the past decade, as more practices have entered the arena of Value-Based Care, practice operational functions have increasingly become an after-thought. The promise of big bonus checks (real or imagined) has created an environment in which small and mid-sized practices have shifted their focus toward RAF, gap closure activity, quality indicator capture, among other activities. While these are all important, is taking your eye off the ball with respect to core practice operations concepts, inadvertently sabotaging the same VBP performance that your focus and effort is intending to optimize? It sure is.

As Value-Based Programs have become increasingly more complex and as early adopters of VBP continue to solve for the performance paradigm under these programs, the needle continues to move with respect to requirements of these programs. Long gone are the days of Pay for Participation, including care coordination or admin fees as a handout. Rewardable quality indicators change on an annual basis, and the evidence accepted in support of those indicators changes almost as often. Over the past few years, one of the largest changes to hit the VBP world (especially in the Medicare Advantage and Medicaid spaces) is the increasing importance of physician practice customer service measures as leading indicators of patient engagement and satisfaction.

With all of these changes and a need to maintain focus on the coding and gap closure activity that are the bed rock for VBP, it is critical to recognize your practice’s blindspots with respect to other operational activity. Through our firm’s advisory work and interactions with practices of various sizes over the past few years, we have found five areas that consistently come up as requiring renewed focus. While most may not come as a surprise (most practices will tell you how important they are), we have found that few practices recognize first that there is a correlation between strong operational controls in these areas and their VBP performance, and second that they have allowed their practice’s performance in these areas to slip.

Key operational areas:

• Credentialing: Value based programs are generally tied to population health management, and in order to manage a population, your practice must be linked to a population. This is a function of an attribution methodology agreed to between your practice and a payor. There is no way for that payor to link the clinicians in your practice to their members, if your clinicians are not credentialed and linked to your contracts. Seems simple… however many practices do not leverage a well documented and operationally disciplined process when it comes to credentialing (both initial and recredentialing). Time is of the essence in this case, and delays impact both fee-for-service collections and VBP performance results.
• Charge Capture: Incredible strides have been made, industry wide, in coding and condition capture, as the industry has matured in its use of ICD-10, and as risk adjustment activity has become increasingly important. I have seen, however, that procedure capture in physician offices continues to be a challenge. This is often brushed off because non-surgical practices, especially primary care offices, generate most of their income from E&Ms. The reality is that fee-for-service revenue is likely being left on the table, and more pertinent to this discussion, you are relying on document submission in order to gain credit for quality indicators, rather than claims data. This invites errors and omissions into the process as well as escalating your operational cost to manage your VBPs.
• Collections: It may be a bit of a surprise that I include fee-for-service collections in a discussion about VBP performance, but in a world where payors do not have direct, real time access to an EMR, the claim is now and will continue to be, the source of truth for data related to their members (and your patients). FFS collections is a barometer for how much of that data is making its way into the performance reporting (and ultimate payouts) of your VBPs. How are denials handled? If claims are not transmitted properly what is the lag in getting these issues addressed?
  • If you are operating a small to mid-size practice, and especially if you have an outside vendor handling your billing and collections, are you simply managing based on month to month revenue variances? If larger accounts receivable issues are discovered, are settlements, designed to accelerate cash flow, inadvertently impacting the numerators and denominators of your VBP measures?
• Scheduling: The changes made to Medicare STAR ratings over the past few years, have shifted the pendulum away from clinical quality, and placed a significantly greater emphasis on patient (member) satisfaction. Tripple weighted measures for access and availability have been hugely problematic for payors. This impacts your practice from a VBP perspective in two ways. The first, the revenue side of the shared savings equation is dramatically impacted by plan STAR rating. The second, payors have begun to implement both incentives and disincentives around performance as ancillary portions of VBP agreements.
  • The ability for patients to easily reach a practice representative, obtain an appointment within (their perception of) a reasonable amount of time, and to be seen without a protracted waiting room experience are now critical elements to VBP performance.
• Patient Interaction (Non-Clinical):Similar to access and availability, general satisfaction with the interactions of your practice are also being measured. This is not simply a measure of the “Bed side manner” of the clinician, but is a function of the overall appointment experience, beginning with making the appointment, and ending with any required follow-up or referral. In a day and age where there is zero tolerance for a gruff demeanor from the check out person at your local grocery store, it is surprising that practices turn a blind eye to the way their teams treat their patients.

Over the course of the next week, we will be following up with a series of articles that dive deeper into each of these areas, further articulating their connection to VBP performance and providing a few simple steps that even a small practice can take to sure up their operations. Practice leaders need not micro-manage these processes, rather, implementing a few key performance indicators, that can be reviewed periodically, can help to provide peace of mind that these critical practice operational areas are functioning smoothly.

Contact us at info@copehealthsolutions.com or 213-259-0245 to learn how we can assist you in improving VBP performance.