GE Healthcare Camden Group Insights Blog

Top 10 Considerations When Transitioning Physicians to Payment-for-Value

Posted by Matthew Smith on Mar 5, 2015 10:35:00 AM

By Tawnya Bosko, MHA, MSHL, MS, Senior Manager, The Camden Group

change-ahead-signWith increased focus on payment based on value, physician practices and those involved with physician practices need to plan for how to transition to new reimbursement models. Here are the top considerations to keep in mind when implementing value-based structures:

1. How do you define value? 

For all the talk of compensating physicians based on value as opposed to volume, there is no consistent methodology for measuring “value.” Often, payers define value in different ways, making it difficult for physician practices to understand what is required of them in order to meet criteria. Leadership should define what value means to the practice with insight from key payers. Typically, initial steps in measuring value are based on compliance with designated measures from the Healthcare Effectiveness Data and Information Set, but depending on the program, different criteria may be used. Further, the practice may include measures that it has identified as needing improvement, such as patient access, completing notes, meeting meaningful use, or responding to lab results in a timely manner.

2. How do you report on value?

Once the practice has determined the clinical measures or other criteria that will define value, it must proactively assess information system readiness for reporting on these measures. Historically, many payers have tracked these values based on claims data. Practices must be able to monitor, track, and report on performance related to value metrics. Assess the system, and ensure that necessary data can be extracted efficiently and accurately for reporting. Build custom fields within the electronic health record (“EHR”), or consider an add-on reporting tool if needed.

3. How do you document value?

Just as important as determining how to generate reports to measure the value metrics, practices must determine how physicians and other providers should document their work within the EHR in order to ensure their results are captured. Often, EHRs have several ways and areas in which documentation of a certain procedure or services can be documented. Best practice is determining the field or area to document each measure so that it is clearly communicated to physicians and easily reported on, retrospectively.

4. Incentive program - carrot or stick?

Once the metrics to measure value have been determined, what is the incentive (carrot) or penalty (stick) for meeting or failing to meet value as defined by the group? There must be enough incentive to gain buy-in so that physicians do not feel as though extra work is being added without additional benefit. And, there must be enough penalty at stake for the program to be taken seriously. It is about finding the right balance. Is it a withhold on revenues with the opportunity to earn X times the withhold in return if measures are met? Is there a “direct” line of sight between the incentive earned by physicians and the impact on their compensation? There are many models that could be implemented to meet the practice’s needs.

5. Educate, educate, educate.

This point cannot be emphasized enough. Often, healthcare leaders think the difficulty is in defining value, measuring value, and designing the incentive program. While those can be complex, educating the physicians on the measures, model, and how to document them is a very important step and could make or break your program. Remember that these situations often involve changing the way a physician has practiced and/or documented and that it takes time, education, and re-education. Ensure the appropriate processes and tools are in place to communicate and educate effectively.

6. Living in a grey world/burden of value.

Understand that during this transition to payment-for-value, physicians are living in a grey zone. They are expected to take extra steps to meet value criteria, but the majority of reimbursement may still be based on a fee-for-service or volume-based methodology. Essentially, they are asked to spend extra time with patients and on documentation in order to meet quality measures but also to continue to meet their productivity targets in order to sustain the viability of the practice. Typically, the burden of many of the value-based measures falls hardest on primary care physicians. Be aware of this when designing incentive models. Do not do too much at once and overwhelm physicians to the point where they give up.

7. Transparency of data.

Physicians, rightfully so, are often skeptical of performance-related data. They have questions...make sure tyou have answers. Be transparent with data. If a physician asks for the names of patients where they failed on a certain measure, ensure the information is provided. It is important to not only be transparent with data but to build confidence in results.

8. Timeliness of results.

Be timely with reporting. Provide information to physicians in a timely and regular manner so that they are able to improve any deficiencies in the measurement period. Do not wait until the point where it is too late to correct issues for the current performance year. It is in the practice’s interest to improve each physician’s performance. Use the data and reporting to provide feedback and to help them be successful in the program.

9. Impact on total compensation.

Understand the impact that the design of the incentive program has on total compensation. What percentage of total compensation does the incentive (or withhold) represent? Does the physician employment agreement need to be revised to incorporate the incentive model? If physicians are on salary guarantees, how is that addressed so that the incentive/penalty falls on them and not the employer?

10. Engage payer partners.

Work with payer partners and do it early. Discuss their needs when measuring value and pursue discussions on how they can support the transition. Make it a collective effort where initiatives are streamlined and convergent. It is not practical for practices to have multiple different models for multiple different payers; be open with major payers, and develop a program that is supported uniformly.

As medical groups and hospitals that own medical groups look for ways to be more efficient and seek stability in a quickly changing marketplace, embracing a transition to value-based reimbursement is necessary. The focus should be on managing the care of a population, and incentive models should be designed with the end goal in mind.

bosko_headshotMs. Bosko is senior manager with The Camden Group and specializes in designing and implementing clinical integration, high growth medical service operations (“MSO”) and finance, physician hospital organization (“PHO”) and MSO development, managed care strategy, and physician alignment. She may be reached at tbosko@thecamdengroup.com or 310-320-3990.

Topics: Payment Reform, Payment Models, Tawnya Bosko, PFV, Payment-for-Value

Top 10 Survival Tips for Physicians Straddling Fee-for-Service and Fee-for-Value

Posted by Matthew Smith on Feb 19, 2015 2:45:00 PM
By Teresa Koenig, M.D., MBA, Senior Vice President and Chief Medical Officer and Tawnya Bosko, MHA, MSHL, MS, Senior Manager, The Camden Group

Volume-to-value, The Camden Group, Tawnya BoskoTransitioning payment systems from volume to value is a recurring theme in healthcare delivery. With this increased focus on payment based on value (“PFV”) as opposed to volume (fee-for-service or “FFS”), physician practices, or those involved with physician practices need to plan for how to transition to new reimbursement models. While challenges exist around every aspect, one reality is physicians have the largest impact in driving changes in cost and quality (i.e., value). The additional reality is that physicians must deliver care in both the fee-for-service and payment based on value worlds – a difficult actuality for those trained and living in a FFS system. Here are the top considerations for physicians that will allow success in both fee-for-service and payment for value systems as they begin to understand and transition to a value-based world.

1. Accurate coding. As electronic medical records become the norm, coding accuracies become more critical for both payment and population health data tracking. Busy practitioners often miscode, mistype, and use incorrect templates. This can result in incorrect documentation and/or insufficient documentation. These inaccuracies can lead to delayed billing and incorrect data for quality driven reimbursement and health plan audits. Educate and assist physicians in accurate and appropriate coding practices. This will be increasingly important with the transition to ICD-10.

2. Patient engagement. A physician’s understanding of the patient engagement process, strategy, and how it affects their daily practice is crucial for engaging patients and improving patient satisfaction. Whether the strategy has multiple IT facets (i.e., open access scheduling, patient portals, etc.) or paper-based educational materials and other tools, it is necessary for the physician to understand the goals and their role in the strategy. Engaging patients in their care will result in clinical and financial success in either payment model.

3. Care management. Faced with a plethora of programs, physicians may not be aware of how the numerous care management, disease management, or transitional programs impact their patients or the care they deliver. Programs need to include physician leadership and buy-in for success. Make the programs easy to access and support physicians – again these programs can drive clinical and financial success in both payment worlds.

4. New care delivery models. Patient-centered medical homes, chronic care service lines, accountable care organizations…each of these “new” delivery models has, at its core, the same goal: improving the overall value of healthcare and improving patient health. Identifying high risk patients and providing appropriate and early interventions to keep the patients healthier is integral to success and promotes improved quality, whether in a value-based or volume-based system. Engaging in more effective care coordination not only supports more effective referral networks but assures satisfied patients.

5. Price transparency. As patients become more engaged in their healthcare and responsible for larger shares of the financial responsibility of their healthcare, they want and need to know what their portion of the cost for services will be. This is good in a value-based system because it allows patients to make educated decisions regarding their healthcare. This is also effective in a volume-based system because if a provider is able to provide accurate cost estimates to patients, it then also enables them to collect the patient payment responsibility at the time of service. Increasing cash collections and decreasing resources needed to collect on the back end improves the revenue cycle while decreasing operational expense. Providers should use tools to manage insurance eligibility and estimate patient responsibility at the time of service to become more transparent.

6. Clinical transparency. Physicians are unaccustomed to having their notes in the patient medical record shared with patients. Ultimately, the medical record is the patient’s information, and they have a right to access it. Patient portals and other tools have eased the burden of access. Physicians should embrace this process, while following policies for disclosure. Providing patients with access to their information will ultimately help engage them in their healthcare and lead to improved outcomes. Providing patients with access to their information also has been shown to reduce medical malpractice risk, which is beneficial under either structure.

7. Preventive medicine. Embrace preventive medicine services. Healthcare reform has promoted access and coverage to preventive medicine services such as physical exams, health risk assessments, annual wellness exams, and other visits that focus on the overall well-being and health status of the individual. Again, this is necessary to improve healthcare outcomes and value but also generates additional appropriate visits in the volume-based world.

8. Timely completion of records. Whether for paper-based medical records or the electronic medical record, physicians should strive on getting their notes done in a timely manner. Completing notes as soon as possible after the patient visit is a good practice for many reasons:

  • The physician has a sharper memory of the visit and can more accurately convey information to the record;
  • It allows the practice to bill more timely for services, thereby increasing cash flow;
  • It allows crucial medical information to be accessed, if necessary, by other members of the healthcare team;
  • It enables information that recaps the information from their visit to be given to the patient at the time of service or shortly thereafter, thus allowing immediate engagement.

Timely completion of records not only improves overall value, but it is also best practice in a volume driven system.

9. Flexible access and appointments. Many people have very busy schedules and limited flexibility for routine healthcare visits. Providing non-traditional appointment hours (early mornings, evenings, and weekends) promotes patient compliance with follow-up visits and is less disruptive to both the schedules of working adults and a typical school day for children and adolescents. More convenient appointment times generate additional appointment volume for providers and improve patient satisfaction. Additionally, flexible access such as an after-hours answering service that is also able to triage calls and schedule appointments not only improves the quality of service provided to the patient but also helps fill providers’ schedules.

10. Patient satisfaction measurement and ratings. Measurement of patient satisfaction continues to be tied to reimbursement. Embracing patient satisfaction measurement in a practice is a positive, proactive step to take in transitioning to payment for value. Using a reputable survey tool to query the practice, results can then be compared across practices and regions. Pay attention to online ratings of physicians in the practice. While patient satisfaction and online ratings are becoming a large component of value-based care, they also have an impact on volume as patients begin to use online ratings to select their physician.

Teresa KoenigDr. Koenig is a senior vice president and chief medical officer with The Camden Group who specializes in developing and designing clinical integration strategies, medical management programs, and value-based care delivery and payment models. She has worked with a variety of healthcare organizations, from individual physician groups and health systems to academic health systems and Fortune 50 companies. She may be reached at tkoenig@thecamdengroup.com or 310-320-3990.



Tawnya Bosko, The Camden Group, Ms. Bosko is senior manager with The Camden Group and specializes in designing and implementing clinical integration, high growth medical service operations (“MSO”) and finance, physician hospital organization (“PHO”) and MSO development, managed care strategy, and physician alignment. She may be reached at tbosko@thecamdengroup.com or 310-320-3990.


Topics: Payment Models, Tawnya Bosko, PFV, Payment-for-Value, Teresa Koenig MD

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