Practice Management: The Road AheadHow Hepatologists Can Contribute to Value-Based Care
Section snippets
Varying Degrees of Risk: Different Value-Based Models
There are essentially 4 major models of value-based care, with increasing levels of risk.3 Category 1 reflects standard fee-for-service (FFS) care with no link to quality or value. With category 2, although still on the backdrop of FFS, foundational payments are provided to build infrastructure for value-based care and additional bonus payments are tied to either simply reporting quality or performance in select quality measures. Most systems currently have the bulk of their contracts in this
General Construct for Success in Value-Based Care
With any value-based contract, each patient essentially is associated with an allowable spend. Depending on the actual spend, which takes into account the amount paid by claims plus overhead administrative costs, there will either be a surplus or loss associated with caring for an individual patient. If your allowable spend is greater than your actual spend, you generate savings. Across your population, therefore, you generate large shared savings or losses depending on how efficiently your
My Patients Are Sicker
The greatest determinant of allowable spend is the complexity and health status of your patient. We frequently hear physicians state that their patients are sicker. So how is anyone, including the payor, able to make this determination if we do not specifically and accurately code for the conditions that our patients have? Diagnosis codes (International Classification of Diseases, 10th revision) are used to generate risk scores, which then modify the allowable spend for that individual patient.
Controlling the Total Cost of Care: The Bottom Line
In any value-based arrangement, the ultimate goal is to improve quality and decrease the total cost of care. Although increasing the allowable spend to account for the severity of a patient’s clinical conditions is one side of the equation, the opposite side of the equation is to control unnecessary costs.5 There are a number of opportunities for hepatologists to help in this arena, including reducing redundant laboratory tests that may already have been performed at an outside institution,
Know Your Accountable Care Organization Status and Contribute to Collective Success
In 2015, the Medicare Access and Child Health Information Program Reauthorization Act was passed with bipartisan support. This repealed the Medicare Sustainable Growth Rate13 as the method for Part B payments (FFS) and replaced previous programs such as Meaningful Use, Physician Quality Reporting System, and Value-Based Modifier. There are 2 paths to choose from: the Advanced Alternative Payment Model or the Merit-Based Incentive Payment System (MIPS). For systems participating as an Advanced
Hepatologists as Primary Care Providers: To Be or Not to Be?
For hepatologists who are part of an ACO, there a number of quality measures, in addition to those specifically related to liver patients, that they can impact. Perhaps the most obvious include colorectal cancer screening, influenza vaccination, and body mass index assessment with counseling. Most value-based contracts also incentivize on standard quality measures. How the system performs on quality can either serve as a gate for sharing in savings or have its own associated dollars for
Summary: Empowering Hepatologists to Engage System Leadership
By understanding the central role they can play in a system’s success in value-based care, hepatologists can engage rather than react. As described earlier, there are several ways hepatologists can engage (Table 1), including improving coding specificity, participating in quality improvement work, and supporting efforts to reduce costs. The degree to which each is relevant depends on the specific context within which the hepatologist works. Although hepatologists can play a key role in this
References (13)
- et al.
Systems-based strategies to consider treatment costs in clinical practice
Clin Gastroenterol Hepatol
(2020) - et al.
Declining hospitalization rate of esophageal variceal bleeding in the United States
Clin Gastroenterol Hepatol
(2008) - et al.
Mirror, mirror 2017: international comparison reflects flaws and opportunities for better U.S. health care. The Commonwealth Fund
- et al.
The high burden of alcoholic cirrhosis in privately insured persons in the United States
Hepatology
(2018) Alternate Payment Model (APM) Framework. The health care payment learning and action network (LAN)
- et al.
CMS HCC risk adjustment model 2019: winners and losers
Cited by (1)
Practice Management: The Road Taken and the Road Ahead
2022, Clinical Gastroenterology and Hepatology
Conflicts of interest The authors disclose no conflicts.