Value-based care is the way of the future!
If you’re not already using coding (CPT, DX, HCC, RxHCC) and HEDIS quality measures to quantify the quality of patient care to payers, time is running out.
Payers across the board are rewarding facilities that provide adequate data on patient conditions – and those who don’t will experience revenue decline through changes in bonuses, star ratings, and pay-for-performance (P4P).
CMS has announced that the payment year (PY) 2020 hierarchical condition category (HCC) risk adjustment model will use the Alternative Payment Condition Count (APCC) model for blended risk score calculations. For PY 2020, risk scores will be calculated as follows:
- 50% using diagnoses from encounter data, fee-for-service claims, and Risk Adjustment Processing System (RAPS) inpatient records under the APCC model (Medicare Advantage model)
- 50% calculated from all RAPS records and fee-for-service claims under the 2017 CMS-HCC model (your present model)
Why is this important? The model focuses on the number of conditions that an individual beneficiary may have, with the model adjusting as the number of conditions increases. It relies on detailed coding and measures to provide a full picture of patient condition and treatment plan; if these are not accurately recorded in the billing system, there is a financial impact:
- Payer – less funding for patient
- Patient – reduced coverage so greater out of pocket cost
- Facility/provider – no bonus payment, potential loss of insurer-allocated patients or cancellation of contract with insurer
But it goes beyond coding and quality measures…
In a recent article, RevCycleIntelligence predicted that most value-based contracts will include risk for providers within 3-5 years. And last week, CMS released its Primary Care First (PCF) initiative, which aims to improve patient care while managing health care costs. The initiative provides new payment models for providers to boost management of patients with chronic illnesses and avert higher hospital costs. In return for a level of financial risk, providers will gain a more predictable revenue stream and reduce health care provider burden. NACHC is currently reviewing the initiative to determine if/how health centers can get involved.