The shift to value-based reimbursement presents a major growth opportunity.
New models of dc reimbursement are on the way. Do you understand how they’re about to affect your practice—and your income—in the near future? That’s the more important question, because change isn’t just coming, it’s already here.
Medicare and the major insurance companies have been conducting trials over the past few years and have recently announced they intend to roll out new payment models across the country, in less than two years’ time. As doctors and small-business owners, nothing gets our attention as much as major changes in how healthcare practitioners get paid—and this time, for once, it can be to our benefit. But only if we adapt to the coming changes spreading like wildfire.
The major models
From a macro perspective, the days of adjusting patients and being paid separately for each service performed are numbered. What’s taking its place (and we’re not talking five years in the future, but rather in 2017) is the move from fee-based reimbursement to value-based reimbursement. It actually has started in the medical and hospital communities already, but is moving into all healthcare provider models in 2017, as recently announced at the 2015 Healthcare Information and Management Systems Society (HIMSS) conference in Chicago.
Value-Based Reimbursement: This is now the rage among the healthcare third-party payers, provider networks, and the new reimbursement model designed by the government. Instead of providers being paid by the number of patient visits, itemized services performed, and tests ordered (fee-for-service), their payments are based on the value of care they deliver.
Currently, providers have an incentive to provide more services because they get paid for each service, and the more times they perform a surgery or a procedure, the more income they generate. Providers should only offer the care they believe is beneficial and necessary for the patient to improve. If only that were universally true!
Whether appropriately or fraudulently, providers find ways to justify the care they provide. Payers want to get out of the game of rewarding providers for performing excess services and paying for defensive medicine, unnecessary care, fraudulent care, and overutilization.
They want to pay for a case-based diagnosis and the value of the care provided. For a few years there will be a blend of service payments combined with bonus payments for outcomes and the value of patient results and satisfaction.
Patient-Centered Medical Home (PCMH): This model was proposed by the major medical associations in 2007. It is, in essence, an enhanced primary care delivery model that strives to achieve better access, coordination of care, prevention, quality, and safety within the primary care practice, and to create a strong partnership between the patient and primary care physician.
In this model, payers often reward providers with per-member, per-month “bonus” payments for improving primary care services for each patient in the medical home. Like Accountable Care Organizations (as described below), the medical home model is referenced many times in current health reform efforts as one way to improve health outcomes through care coordination.1 You as a DC can be a member of the “medical home” and function as an integral team member providing chiropractic care as part of a patient’s network or neighborhood of providers—and still practice in your own clinic.
Accountable Care Organization (ACO): This model is also based around astrong primary-care core. But ACOs are composed of many “medical homes,” i.e., primary care providers or practices that work together. Some have even dubbed ACOs the “medical neighborhood.
ACOs are responsible for the cost and quality of care both within and outside of the primary care relationship. As such, ACOs must include specialists and hospitals to control costs and improve health outcomes across the entire care continuum.
ACOs by nature are larger than a single medical home or physician’s office. There are many benefits of the ACO structure over the medical home model, including better managed care for a greater population with a larger budget. Spreading dollars across a wider range of patients and conditions allows for better overall cost management, less variation within the population, and the ability to track and trend for quality.1
Being connected to this neighborhood requires you to understand protocols and be electronically connected to the other providers in the neighborhood to facilitate collaboration and point-of-care information on those patients.
By the numbers
According to the National Committee for Quality Assurance (NCQA), the number of PCMHs is approaching 7,000.2 And over the past year alone, approximately 120 organizations have become ACOs in public and private programs, bringing the total to 744 and covering nearly 25 million patients.3
The move to value-based reimbursement is exactly why chiropractic is, for the first time ever, poised to move from the fringes (on average, 8 percent of the U.S. population visits a DC) to considerable adoption. But we have to show empirically, through aggregated data, that chiropractic is a savings center versus a cost center.
While we know that it is, government and private payers need proof. And if we give it to them, they’ll not only recommend but require certain patients be seen by a chiropractor prior to undergoing more costly forms of treatment; namely, injections and surgery.
Gerard Clum, DC, in an interview with Cleveland Chiropractic College, said, “We don’t add cost to the system; we take expense out of it. This fact involves a huge shift in thinking for folks in the insurance world because they don’t see chiropractors in that light. It’s very important that we keep bringing this concept of expense reduction to the attention of people in the insurance and policy worlds.”4
Why data matters
Chiropractors won’t gain and help more patients under the new payment models if they don’t have (and share) the data that proves the efficacy of chiropractic. It’s not enough to have anecdotal evidence.
To this effect, your ability to contribute is actually straightforward if you follow three steps.
- Adopt a certified EHR software into your practice to document your daily visit encounters and patient health
- Use your professional protocols and guidelines and document your care You can easily capture data with outcome assessment tools such as basic patient questionnaires to quantify progress and satisfaction with the care received.
- Implement software with the ability to display those results as metrics and data to show that you have successfully achieved recovery or that you should modify the care You want to demonstrate that whatever care pathway is needed, you have data to guide you.
This data must be aggregated with other information about your practice to show the value of care delivered.
Essentially, it is your report card demonstrating that you get good results with your overall slate of patients for specific conditions. If you are a reliable provider, then medical homes and ACO allopathic providers will want to refer more patients to you, and refer you more frequently.
Ultimately, this can result in your having a waiting list of referrals because your data demonstrates the quality of your care. Value results in more reimbursement, and data demonstrates the value.
Leading from the front
So, how do you not only benefit from these changes but indeed thrive as a result? As stated in an article by Aubrey Westage, senior editor of Physician’s Practice, to take advantage of value-based reimbursement opportunities, doctors can:
- Ask payers about value-based models and incentives,
- Identify the metrics payers are using to assess quality,
- Implement patient satisfaction surveys and take steps to improve,
- Implement a certified EHR that functions specifically for that provider specialty,
- Add value-based incentives to doctor compensation, and
- Implement a practice-wide strategy to address 5
Technology is allowing chiropractic to make its truths known to a wider audience. We owe it to humankind to expand the benefits of chiropractic care to the masses. We will never get beyond single-digit market use of chiropractic by doing the same things we’ve done for the past 100 years.
Look for opportunities to exchange health information with the entire healthcare community in a format and delivery model it understands. Some DCs may fear a report card on their practice. But data helps us all adapt and improve. As a profession, we have nothing to fear.
Steven Kraus, DC, FIACN, DIBCN, FASA, FICC, CCSP, is an accomplished practitioner, author, and business owner. He has owned 18 chiropractic practices, and is the chief market strategy officer for ChiroTouch, an integrated office management and electronic health records software company. He serves on numerous national committees related to government relations, clinical quality assessment, and health information technology. He can be contacted through chirotouch.com.
1 Accountable Care Facts. “What is the difference between a medical home and an ACO?” http://www.accountablecarefacts.org/topten/what-is-the-difference-between-a-medical-home-and-an-aco-1. Published May 2011. Accessed July 2015.
2 National Committee for Quality Assurance. “The Future of Patient-Centered Medical Homes.” http://www.ncqa.org/Portals/0/Public%20Policy/2014%20Comment%20Letters/The_Future_of_PCMH.pdf. Published February 2014. Accessed July 2015.
3 Muhlestein D. “Growth And Dispersion Of Accountable Care Organizations In 2015.” Health Affairs Blog. http://healthaffairs.org/blog/2015/03/31/growth-and-dispersion-of-accountable-care-organizations-in-2015-2. Published March 2015. Accessed July 2015.
4 Cleveland Chiropractic College. “Interview with Gerard Clum, DC.” http://www.cleveland.edu/hit/julaug-2013-vol-6-no-4/coming-changes-health-care-what-dcs-need-know-interview-gerard-c/clum3. Published July 2013. Accessed July 2015.
5 Westgate A. “Getting Paid for Value: Defining New Reimbursement Models.” Physicians Practice. http://www.physicianspractice.com/fee-schedule-survey/getting-paid-value-defining-new-reimbursement-models/page/0/4. Published January 2014. Accessed July 2015.