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Getting Paid in a Value Based World

You’ve got to love CMS. They took a simple concept like “if you lower the cost of delivering care to a population of patients, we’ll
share the savings with you” and exploded it into a Rube Goldberg machine of pieces, parts, rules, constraints and exceptions.

Did you know, for example, that CMS calculates expenditure trends using three prior benchmark years and weights them 60%, 30%, 10%? But, did you also know that in second agreement periods that began in 2016, CMS doesn’t use this weighting? They weight the benchmark years equally. It’s a distinction only a mother could love.

And, don’t even get me started on claims runout rules, truncation, varying minimum savings rates based on beneficiary counts, and changing quality performance standards. Ruben Garrett Lucius Goldberg would have been proud.

Given this complexity, it’s probably not surprising that less than 35%[1] of provider organizations in the Medicare Shared Savings Program (MSSP) are getting checks from CMS. What’s also not surprising is the millions of dollars these organizations have spent on analytics, patient engagement, care management/coordination, and data warehousing solutions. Vendors supplying these solutions promised success. They promised results. They promised checks.

What happened? Why have these investments failed to deliver a real return? In this series, we will explore the real problems that provider organizations taking risk face. You will see that, while analytics, care coordination, etc., are important and necessary solutions to actual issues that providers have to deal with, they are simply not sufficient to consistently and predictably deliver positive financial results in a value based world.

Many, if not most, providers in risk oriented programs are suffering from performance anxiety. They keep trying stuff – care model redesign, transitions in care management, referral management, self service reporting, provider incentive programs and a whole host of other well intentioned things – and they are simply not delivering the goods. There’s no doubt that some of these initiatives are legitimately improving the patient experience or engaging providers better or driving out care delivery variation. These are real benefits and they are helpful. However, they are not necessarily helping provider organizations deliver positive financial results in a value based world.

As an organization with its roots, trunk and limbs squarely in the revenue cycle, we have a single minded focus on how to get providers paid. As Bill Murray’s character, Peter Venkman, said near the end of the original "Ghostbusters" film: “… for a moment, pretend that I don’t know anything about metallurgy, engineering or physics and just tell me what the hell is going on,” we don’t know anything about how to organize emergency departments more efficiently, redesign care models, reconcile medications or do a whole bunch of other stuff that’s better left to folks with a lot more years of schooling than we have. In other words, when it comes to medicine, we, like Venkman, are poor scientists.

However, we do know what it takes to get providers paid. And, when we look closely at all the complexity associated with the design of value based programs and the complexity (and costs) associated with the investments provider organizations have made to deliver results, we think, respectfully, that providers may have been missing a trick.

It turns out that all the rules in Title 42, Chapter IV, Subchapter B, Part 425, with all of the associated subparts and sub-sub parts, can be reduced to a fairly simple equation: lower cost and utilization, meet the minimum quality standards that apply to you, and manage HCC risk scores… and get paid.

That’s it. The rules don’t say anything about implementing a care management solution. They don’t say anything about having to invest in a data warehouse… early binding, late binding, book binding or otherwise. They don’t require you to be proficient at analytics. And, they definitely don’t require you to integrate with every EMR in your provider network.

The rules actually require you to… wait for it now… follow the rules! I’ll say it again… manage cost, utilization, quality and risk – the way CMS wants you to – and get paid.

Okay, okay… I know what you’re thinking: that’s easy to say, but hard to do; or, you aren’t telling me something I don’t already know; or, I never really liked "Ghostbusters". We can’t help you with your taste in movies, but you’re right… it is easy to say and hard to do. All we are arguing for is focus. We’re arguing that, if you are a provider taking risk and your objective is to deliver a positive financial outcome – i.e., get paid – then you need to focus your attention on the metrics that matter and on the process for improving them.

For more information on a successful transition to VBR, check out our other posts: "What's Happening with Value Based Reimbursement in 2017" and "Managing Stakeholder Interactions: The Key to Success with Value Based Programs".


Interested in learning more about our Value Based Reimbursement Solution Approach?    Learn More!

 


[1] 2015 Medicare Shared Savings Performance Results, https://data.cms.gov