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MACRA MIPS – What it Means for Physicians?

MACRA MIPS (The Medicare Access and CHIP Reauthorization Act of 2015 – Merit-based Incentive Payment System) is a program that caters to physicians’ finances under Medicare.

The program is now in its fourth year, and it would not be wrong to say that it facilitated the physicians’ reimbursement process.

Key Elements of QPP MIPS

MIPS program has four categories that cater to meaningful quality healthcare services.

  • Quality
  • Improvement Activities (IA)
  • Promoting Interoperability (PI)
  • Cost

The quality category replaced the current PRQS (Physician Quality Reporting System) and reflects the efforts to improve the quality of care.

Improvement activities translate patient convenience and satisfaction in quality healthcare delivery.

Promoting Interoperability replaced Advancing Care Information (previously known as the meaningful use program) to integrate technology in healthcare.

The cost category replaced the value-based modifier program and translates the efficiency of the cost factor.

Each category has different weights. The respective percentages change each year under MACRA MIPS. Eligible clinicians, who exceed the minimum performance threshold get positive payment adjustments and avoid a penalty of a certain percentage.

MIPS Full Form in Healthcare

Large medical practices already know the implications of MIPS data submission. However, it is small healthcare organizations or non-eligible clinicians that need to understand MACRA MIPS to the core.

Now, the performance bar has gotten high. Although, CMS (The Center for Medicare & Medicaid Services) facilitates small/rural/underprivileged medical practices to much extent. However, the appropriate approach is to consult a MIPS Qualified Registry for MIPS solutions.

What Physicians Can Get from MIPS Reporting?

There are many advantages that eligible physicians can get by submitting data to CMS under MACRA MIPS.

  1. Physicians get to improve quality care.
  2. They can improve ranking among fellow physicians via Physician Portal, thus, improves patient rate.
  3. Against the exceptional performance, physicians can receive incentives.
  4. High achievers can even receive a share from the $500 million bonus pool.

However, MACRA MIPS data submission requires consistent efforts and MIPS consultants to guide through the process.

How to Report MIPS Data?

Eligible clinicians can choose different ways to report MACRA MIPS. However, the easiest and comprehensive way is to report data via the MIPS Qualified Registry as P3Care.

We choose specialty-specific measures to submit data from the list as per the final rules proposed by CMS.

Conclusion

Data submission under MACRA MIPS is a lot to take in, but as the years went by, it is in the best interests of physicians to try to qualify for this quality payment program.

Especially with COVID, physicians have lost millions of bucks to cater to the surge of patients. In such times, incentive payment programs as MACRA MIPS prove to facilitate physician in any way possible. Moreover, CMS also offered flexibility in the administrative load. So, there is no point in avoiding participation in such programs, right?

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MIPS Quality Measures 2020 and Specifications for MDs and DOs

Am I eligible for MIPS incentives in 2022?

The question that we hear a lot. And, I have to say it is your right to know.

Whether you are a general physician or a surgeon, submission of MIPS Quality measures leads the way to incentives.

Why?

The government started MIPS back in 2017 to incentivize eligible clinicians, and in return, improve the quality of healthcare. In short, it ensures ECs submit measures for the good of their patients – they will have permanent access to quality care.

The purpose here is to write down a MIPS Quality measures list that includes at least some measures and leave the rest to update in the future. Therefore, you’ll see some of them if not all; we’ll keep updating it, hopefully.

I also hope to provide info not only for family and general physicians but for specialists too. In an ideal system, the MDs, and DOs work in rhythmic harmony for better care coordination and patient experience.

Difference between an MD and a DO

For those of us who don’t know what an MD is, it is short for Medical Doctor, while DO stands for Doctor of Osteopathic Medicine.

Although they may use all the available methods to treat their patients, including drugs and surgery, DOs believe in a more holistic approach. By definition, DOs emphasize preventive medicine, musculoskeletal health, and holistic care. It doesn’t mean MDs are any less skilled or vice versa. Both are equally capable.

The Expertise of Both Specialists

Both specialists, MDs and DOs, can choose to practice in any specialty. Both lend their expertise to promote the quality of healthcare to patients translating CMS MIPS quality measures.

AMA (American Medical Association) studied that in 2018, up to 57% of more DOs preferred to practice in primary care compared to 32% of the MDs.

The total statistics for DOs participation in primary care were:

  • 9% went for family physicians
  • 8% went for internists
  • 8% went for pediatricians

However, both programs offer a license, thus, it does not matter what program a student pursues.

Define the Quality Performance Category

One of the categories of the Merit-based Incentive Payment System (MIPS) is the Quality performance category! It holds a 45% weight in the total score.

What does it account for?

It measures your performance in clinical activities and patient outcomes. MIPS data submission through Quality measures helps assess health care processes, manage results, and patient experiences. As a result, we can expect the highest quality of care while keeping expenses to a minimum. Hence, the achievement of the value-based care purpose.

Understanding CMS MIPS Quality Measures

  1. Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) 

Diabetes, a menace, to say the least, shadows quite a part of the US population. How can we put a lid on it? Well, the answer lies in value-based care. More importantly, it is MIPS quality reporting that will eventually decrease the number of diabetics across the country.

This particular measure says to submit data on your patients from the age of 18-75 with diabetes who had hemoglobin A1c > 9.0% during the measurement period.

A CMS eCQM is available for this outcome measure. The collection types for this measure include:

  • Medicare Part B Claims
  • eCQM (electronic-clinical quality measure)
  • CMS Web Interface
  • MIPS CQM (clinical quality measure)

Since one of the collection types of this measure is MIPS CQM, you can submit it through a registry. It is one of the most effective of all the MIPS data submission methods thus far.

You can submit it if you are part of the following areas, provided you fulfill the low-volume threshold for MIPS:

    • Family medicine
    • Internal medicine
    • Preventive medicine
    • Nephrology
    • Endocrinology
    • Nutrition/dietician
  1. Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)

Measure number 2 is related to the heart. American Academy of Cardiologists

It includes people aged 18 and above who were diagnosed with heart failure (HF) with a present or past left ventricular ejection fraction (LVEF) < 40% and were prescribed beta-blocker therapy either within a year of procedure in an outpatient setting or at each hospital discharge.

Reporting MIPS through this measure sets the tone for the management of chronic conditions. Gladly, it is available in both eCQM and CQM type, thus acceptable through various sources.

Specialties for which this measure is suitable to include:

  • Cardiology
  • Family medicine
  • Internal medicine
  • Hospitalists
  • Skilled nursing facility
  1. Anti-Depressant Medication Management

Psychiatrists act as pillars of healthcare when it comes to mental health treatment. Especially, their role is critical through the COVID-19 pandemic. Could there be a worse time for mental health issues to rise? Well, it could be worse!

Being grateful and using empathy as a tool to interact with people around us is needed for sure. The description of this measure that we have with us is mostly for eligible psychiatrists. MIPS 2020 presents numerous measures to report with accuracy and data integrity as the two requirements.

It is quality measure #9, according to the official fact sheet released by CMS.

How do we describe it?

It aims to find a percentage of people aged 18 years and above who were treated for mental illness and prescribed antidepressants. As per their depression symptoms, they have prescribed medication for months. You should report the following two types:

  1. First, the percentage of patients who were on antidepressants for at least 84 days (12 weeks)
  2. Second, the percentage of patients who were on antidepressants for at least 180 days (6 months)

Why is this measure meaningful?

It is in line with the prevention and treatment of opioid and substance use disorders. A MIPS consulting firm helps you select the right measures to report. More importantly, it is the accuracy and data completeness that matters to maximize MIPS incentives.

The collection type available for this measure is eCQM. Moreover, the specialties that this measure services include:

  • Family medicine
  • Internal medicine
  • Mental/behavioral health
  1. Age-Related Macular Degeneration (AMD): Dilated Macular Examination

Eyes let us see the beauty around us, thankfully. They show us the world as it is. In this quality measure, people aged 50 years and above are to participate. As an EC, you are to report it once they are diagnosed with age-related macular degeneration (AMD), followed by a dilated macular examination.

Further, it led to the recording of the presence or absence of macular thickening or geographic atrophy or hemorrhage and the intensity of the damage caused during one or more office visits within the 12-month assessment period.

Henceforth, this measure assesses the chronic conditions management area. Ophthalmologists are to report it through their MIPS consultant. MIPS solutions and to send MIPS data via clinical quality measures type is doable with plenty of support from qualified registries.

The collection type for this measure includes:

  • Medicare Part B Claims
  • MIPS CQM

In fact, it is only available for the ophthalmology specialty.

  1. Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care

As the title clearly says, the measure goes against the menace of diabetes and its effect on the eyes. Value-based care becomes viable to bring back quality into healthcare, and at the same time dial-down, healthcare costs.

The measure specifications for clinicians help in its understanding. Our research concluded this measure to be part of the MIPS Quality measures list released officially by CMS.

Essentially, MIPS 2020 covers the continuing process of our healthcare, moving in the right direction. Let us see what the measure means:

“Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months.”

Willing to go after MIPS data submission for this measure? It is most likely to score high if reported accurately. That is where P3 comes in to report to CMS on your behalf. The basics of this measure put it amongst the CQMs and eCQMs. Moreover, it is a high priority measure applicable to the ophthalmology specialty.

  1. Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older

It is a measure that directly informs of the health of our seniors as far as their fractures and overall health is concerned. The meaningful area under discussion here is the Health Information Exchange (HIE) and Promoting Interoperability.

What does the measure exactly mean?

According to CMS, it derives the following explanation:

“Percentage of patients aged 50 years and older treated for a fracture with documentation of communication, between the physician treating the fracture and the physician or other clinician managing the patient’s on-going care, that a fracture occurred and that the patient was or should be considered for osteoporosis treatment or testing.”

It is submitted by the physician who treats the fracture and who therefore is held accountable for the communication. A high priority measure, to begin with, you can use Medicare Part B Claims and MIPS CQMs as its collection types.

As an EC, if you are part of the following specialties, you can choose to report this measure.
• Family medicine
• Internal medicine
• Orthopedic surgery
• Preventive medicine
• Rheumatology

  1.   Advance Care Plan

The Advance Care Plan deals with many branches of healthcare, including Cardiology, Family Medicine, Gastroenterology, General Surgery, Neurology, Obstetrics/Gynecology, and more.

How Do We Describe this MIPS Quality Measure?

MIPS in healthcare defines this measure by the percentage of the patients aged 65 years or older with an Advance Care Plan. This measure is also valid for those patients who document another decision-maker on their behalf as a surrogate on authentic medical records.

Another situation is when the medical records show that the Advance Care Plan was discussed with the patient, but they could not provide a surrogate neither they wished to.

MIPS 2020 Reporting Instruction for Advance Care Plan

MIPS eligible clinicians can submit this quality measure for just one patient seen throughout the performance period. There is no specific diagnosis attached to this MIPS Quality Measure. However, the MIPS Qualified Registry on behalf of physicians can submit data for the quality services provided to the patient based on the measure-specific denominator coding.

It is to note that that this measure applies to all healthcare settings, be it nursing home, etc., except for emergencies.

Measure Submission Type

Individual clinicians, groups, and third-party intermediaries such as a MIPS Qualified Registry submit the related data to CMS. However, only those third-party intermediaries can submit data, which used Medicare Part B claims.

Conclusion

Thus, paying special attention to the MIPS quality measures can maximize the chance to earn positive adjustments and even incentives.

It all depends on the CMS MIPS quality measures that you submit to CMS. Therefore, MDs and DOs, take time to strategize MIPS solutions properly and improve your financial situation.

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MIPS Quality Measures 2019 Vs. 2020 – Registry Investigates

Merit-based Incentive Payment System (MIPS) has entered 2020, and, so have the Quality, Promoting Interoperability (PI), Improvement Activities (IAs), and Cost categories. It is a no-brainer to write a thoughtful comparison between the two years regarding MIPS quality measures.

Hence, we are here to discuss the Quality category in detail; the six measures adding up to the final score; any new requirements; and why P3 Healthcare Solutions is a smart choice to report registry-specific measures.

It’s not about the passing years that we have managed to make it to the next year of value-based care, but the essence of MIPS in Medicare lies in its delivery. Each year calls upon MIPS eligible clinicians to adopt a certain set of measures and activities and report them to the Centers for Medicare & Medicaid Services (CMS). 2020 is no different as long as you are on the right track of submission.

The reporting occurs through legitimate submission methods only, the result of which conforms to performance evaluation and incentive payments.

 MIPS Quality Measures 2019 and 2020 – The Types

I have to admit there are more similarities than differences between the two, because, for starters, they have the same collection (measure) types.

In MIPS 2019 and MIPS 2020, participants get to submit 6 quality measures data for 12 months (from January 1 to December 31, 2019, and January 1 to December 31, 2020, respectively). The amount of data to undergo submission depends on the collection (measure) type.

CMS finalized 6 collection types for both 2019 and 2020 CMS MIPS Quality measures. These measure types include:

  • Electronic Clinical Quality Measures (eCQMs)
  • MIPS Clinical Quality Measures (CQMs)
  • Qualified Clinical Data Registry (QCDR) measures
  • CMS web interface
  • Medicare Part B claims measures, and
  • The CAHPS for MIPS survey

As a rule, participants must submit a total of six quality measures from the above types.

General Reporting Requirements Vary

If you talk about 2019, the data completeness factor was 60%, i.e. clinicians were to report performance data for 60% of their patients eligible for a chosen measure. For MIPS 2020, clinicians are required to report data for 70% of their patients eligible for a certain measure. It is 10% more than the last year which means CMS plans to cover a wider population of patients and bring them into the fold of value-based care.

Quality measures refer to the improved standards of care delivery and patient satisfaction, and the data completeness constraint is an extension of expending one’s expertise to most patients. The increasing performance thresholds also reflect CMS’ vision of encouraging everyone to opt for quality healthcare.

MIPS Submission Types

In the case of MIPS submission types, there are 4 ways to submit quality measures. These include:

  • Medicare Part B claims
  • Sign in and upload (a MIPS consulting service can report on your behalf)
  • CMS web interface
  • API submission which is the direct method of submission

Six Measures

A total of six quality measures was the requirement back in 2019, and in 2020, it hasn’t changed much. We have a total of six MIPS quality measures in 2020 as well. It includes one outcome measure, but in case, the outcome measure is absent, go for a high-priority measure instead.

Practices, groups, and virtual groups with 16 or more clinicians will be automatically calculated on a 7th measure, the All-Cause Hospital Readmission Measure.

The Curious Case of Bonus Points

Although CMS requires improved quality, it doesn’t mean that they don’t want clinicians to target incentives and bonuses. You can qualify for the strict criterion with the help of a Qualified Registry and improve revenue.

Bonus points sound charming enough to know more about their details. Therefore, we will try to find out how to make those bonus points ours and maximize our rewards in 2021 and 2022.

For MIPS Quality measures 2019 and 2020, you can earn bonus points on the following terms.

  • Submit 2 or more outcomes or high-priority measures. It doesn’t apply to the outcome measure or high-priority measure that is already there, but two separate measures are required to get your hands on bonuses. P3, as a MIPS consulting service, reports Quality measures for its clients across the US. Opioid-related measures are part of the high-priority measures list.
  • In MIPS 2020, measures that are part of the CMS web interface don’t qualify for bonuses, but if you report the CAHPS for MIPS along with the CMS web interface, you have a chance to win bonuses.
  • Submission using Certified Electronic Health Record Technology (CEHRT)
  • Besides, six additional points are there for small practices that submit at least one quality measure. Practices include individuals, groups, and virtual groups.
  • 10 additional points for practices that exhibit improvement in their Quality reporting from the previous year.

Conclusion

Before I end this article, I want you to stay illuminated by the present and the future requirements of reporting as long as you have us on your side. P3 Healthcare Solutions prides itself on reporting MIPS for clinicians across the United States. To get in touch, please call 1-844-557-3227.

We have a comprehensive piece written on MIPS 2020 on our LinkedIn page. If you have some questions related to it, you may go through it when you have some time.

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Reimbursement Trends of 2020: MIPS Vs. Fee for Service

As we enter the year 2020, reimbursement challenges also enter another phase. They are getting more and more complex for independent physicians with each passing year. The reasons for this complexity are the ever-changing reporting requirements from regulatory authorities like the CMS, and the differences in contracts among commercial insurance companies. First, the Merit-based Incentive Payment System (MIPS) in 2020 poses a new set of requirements for clinicians. Second, Insurance companies, in general, require more and more data to draft patient outcomes. So, there is not one, but two pressures inherited by clinicians as they step into the New Year. When we talk about the Quality Payment Program (QPP), some new Advanced Payment Models (APMs) are in the development phase regarding Primary Care. Based on them, the decisions that doctors make today can directly reflect on their future revenue. Let’s see some of those reimbursement trends now.

CMS Focuses on Primary Care

In 2020, CMS sets the same E/M coding requirements for office and outpatient E/M activity, as instructed by the American Medical Association (AMA) CPT Editorial Team. The four levels of E/M codes remain intact for new patients with five levels dedicated to regular patients. Another slight change occurs in the conversion factor for Medicare Physician Fee Schedule (PFS) which increases from $36.04 to $36.09. This factor isn’t expected to grow to a greater extent in the next six years. According to Andres Gilberg, Senior Vice President Government Affairs, Medical Group Management Association (MGMA), the reason for this slight increase is due to the lack of adoption of MIPS and APM by clinicians at the pace Congress wanted when it sanctioned MACRA. Clinicians concerning MIPS in 2020 face serious penalty consequences for not reporting MIPS 2020. They won’t be able to get away with it if they don’t participate resulting in a 9% deduction from their yearly Medicare payments. MIPS 2019 reporting determines the potential bonus percentage to be 1.65. To state a strategy that will work, I’d advise clinicians to report MIPS Quality measures in 2020 to come out as a winner in 2022.

APMs Expected to Increase in Number

CMS intended MIPS to lead into APMs eventually, resulting in less reporting burden and a seamless system of financial incentives. However, the number of APMs needs to increase. There was a notion that CMS would revert to fee-for-service and reset the payment model. But that didn’t happen, and we are stuck with MIPS. Conclusively, we need to have more APMs to accommodate the growing number of clinicians. As a MIPS Qualified Registry, P3Care speaks for and on behalf of clinicians to value their unconditional and invaluable service to the people of the United States.

Private Insurance Companies Push for Quality

To show compliance and participate in value-based care systems, private payers continue to pay more attention to outcomes. It is not expected to change in 2020. What the Quality Payment Program has done is that it has increased the risk-sharing capability of the healthcare industry. Consequently, there is never a dull moment with value-based care. Additionally, provider networks will expand to bring in-home care, pharmacy, and other fields categorically. Thus, changing the whole outlook in a meaningful way. In the past, it used to include inpatient, outpatient, and primary care areas only. Private payers looking up to Medicare reimbursement models, as a result, pay attention to patient access, engagement, cost, and quality measures. If doctors are doing all of that they would be on the A-list of providers. By examining closely what the doctors are doing to their patients, private payers will decide to keep the provider or cancel their contract altogether. For instance, if they are sending their patients to a far-away imaging center only because it is in their health plan, they won’t go unnoticed by payers for long. Insurance companies are allowed to terminate their contracts in such instances without prior notice, as United Health has done in the past. Those who do exceptionally well and create a better patient experience are bound to get special invites from provider organizations tagged with bonuses as a reward.

Smaller Practices to Face Payment Difficulties

Mergers are likely to continue in healthcare as payers find cost-effective ways to navigate value-based care. You see, larger organizations have the power to provide better infrastructure to follow MIPS 2020 requirements. In comparison, smaller practices have a lesser chance to comply with what the program requires. Nevertheless, bigger systems have other issues to deal with. As more and more physicians join mega hospitals and provider networks, getting them to follow QPP guidelines and execute coordinated care are two of the challenges they face. Therefore, you focus on either fee-for-service model or value-based care because if you do both incentives won’t match with one another. The next threat to small practices is the rise of retail clinics. A retail clinic is a doctor’s office at the shopping mall where you can get primary care services instantly. You are looking at revolution so to speak. For now, experts are unsure of the affect retail clinics will have on reimbursement rates, so it’s a waiting game from here on. Comment below and share your thoughts if you’d like to. To show you a list of top MIPS consulting firms, we wrote an article titled – Top 3 MIPS Consulting Services in the U.S.

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The Role Of Clinical Quality Measures For Physicians

Since the healthcare industry has taken serious measures to revamp healthcare services, the emphasis on incentive payment programs has increased. MIPS and MACRA, and more offer facilities to physicians that regular payment method can never provide.

Such incentive payment programs come with various quality measures against which clinical data is needed to report. The number of clinical quality measures is so large that it is difficult to manage them for each healthcare provider. Moreover, the requirements for each program be it Meaningful Use (MU), MIPS or others and the implementation of reporting criteria can be quite confusing.

The Center for Medicare and Medicaid Services (CMS) states Clinical Quality Measures (CQMs) for incentive payment programs. The result is not just to pay physicians but the value-based healthcare improvement efforts. These clinical quality measures also put their part in various government or private development projects.

Need of CQMs

Eligible physicians and hospitals submit data to CMS as in MIPS. In return, CMS estimates their performance and reward accordingly while checking that patients are getting the deserved attention from physicians. In addition, it works in favor of the healthcare industry to improve performance categories, falling short in terms of efficiency and quality.

What factors determine success in Clinical Quality Measures Submission?

As per the CMS website, it checks the following parameters to score CQMs.

  1. Use of available resources
  2. Compatibility to healthcare standards
  3. Healthcare outcomes
  4. Patient’s safety and welfare
  5. Coordination among physicians
  6. Patient’s engagement level
  7. Population & overall health standard
  8. Healthcare clinical processes

To maintain the accuracy and transparency in the healthcare system, ONC, Office of the National Coordinator for Health Information Technology (US Government Health and Human Services), monitors the use of EHR and other technologies.

The Development Process of Clinical Quality Measures (CQMs)

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National Quality Forum

Many healthcare industry leaders and stakeholders take part in developing CQMs. However, measures standardized by the National Quality Forum (NQF) are considered as the top priority. Most of the incentive payment programs use their measures because their development process involves extensive research.

Another reason for adopting NQF quality measures is their work and objectives that match with that of CMS. Moreover, their initiative boosts the use of electronic healthcare records (EHRs).

Development Process via CMS

CMS also has its own measure development project known as The Measures Management system. This system is always in its evolution stage and sets values for business processes. The deduced measures also support MIPS and other incentive payment programs and provide an opportunity for their growth.

Real-Life Implementation of Quality Measures

Clinical quality measure reporting accounts for many uses, but its major reliance is on EHR technology usage or Meaningful Use. However, many healthcare providers deem Meaningful Use to be stressful and demanding. Moreover, not every quality measure is for everyone. Thus, there should be some flexibility in the reporting criteria.

CMS has gone to great lengths to overcome reporting issues and streamlined measures under seven categories.  When physicians are reimbursed and incentivize, it becomes obligatory for them to maintain their performance instead of giving quality as a onetime shot.

Clinical quality measures are also a great aspect of Physicians’ Quality Reporting System. Physicians are met with penalties when they don’t report according to the standards.

Thus, MIPS, MACRA, and other payment incentive programs can’t perform their actual functions without efficient marking of clinical quality measures. The key to success is the selection of accurate measures according to the practice and the value-based approach of practicing physicians towards patients.

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3 Types Of Payment Models, Physicians Probably Don’t Know!

Value-based healthcare services have not only changed the patients’ healthcare standards but also the physicians’ payment model. Value-based reimbursement models encourage clinicians to adopt methods that make healthcare easy and efficient. Programs like MIPS & MACRA and more depict a value-based care system and allow physicians to achieve rewards and bonuses. The purpose is value-based reimbursement models are too.

  • Straighten up physicians’ revenue cycle management
  • Make patients empower the healthcare system where they choose their desired service

We have heard many of the benefits and the need for value-based healthcare models, but the proper information about the available models is not very common. Let’s review that.

What are the Available Value-Based Care Models?

There are a few types of value-based payment models with a variety of risks attached and the benefits.

1. Accountable Care Organizations (ACO)

It is a system of hospitals, clinicians, and other healthcare providers to provide organized and high-quality services to Medicare beneficiaries. It was started to help patients receive up-to-the-mark services at the most appropriate time. It means that in case of emergencies or other scenarios, patients don’t have to wait to get to the relevant doctor.

This organization ensures that patient only bears expenses for those services that are absolutely necessary to treat an illness. Redundant medical services are reduced by eliminating medical errors that occur while diagnosis or treatment.

Healthcare providers volunteer in this program to get shared savings if the ACO fulfills the standardized healthcare criteria with reduced expenditure.

Risk Factor Involved in ACO

It is not like ACO volunteers always end up adding a bonus to their revenue cycle, but the financial risk is also involved. When able to meet the requirement, physicians have a jackpot, but on the other side, they also have to bear shared losses if any.

For shared loss, healthcare providers have to pay Medicare as compensation for not delivering value-based care to patients.

This value-based reimbursement model is not just about value-based medical procedures but also supports volume-based services. However, the evaluation is based on quality, safety, and experience.

2. Bundled Payment for Rendered Services

This payment model pays physicians not for each service but as a whole series of services. Clinicians receive collective reimbursement for treating a medical condition, including all the charges for physicians and the types of rendered procedures.

For Instance,

If a patient undergoes a surgical procedure, CMS (The Centers for Medicare and Medicaid Services) sets a collective payment for surgeons, an anesthesiologist. It then pays a total amount rather than paying separately to each clinician.

Risks Attached with Bundled Payment Model

A certain level of risk is also involved with this type of payment model same as the ACO. Physicians get to full their pockets when they collectively reduce the incurred cost. Otherwise, they get will have to bear the loss.

Thus, this practice requires standardized procedures so that, all stakeholders get the rightful reimbursements.

3. Patient-Centered Medical Homes (PCMH)

It represents the healthcare payment model in which a primary care physician coordinates the patients’ healthcare. This payment model manages and handles all the needs of the patient in a centralized setting.

It’s certification highlights that the physicians are capable of providing healthcare in a patient-centered setting with team-based methods. Moreover, it also ensures consistent care quality for patients.

Patients are allowed to develop a one-to-one relationship with their physicians, and it governs the medical and environmental factors.

This payment system has shown great potential in reducing the unnecessary cost expenditure. According to a Maryland – based PCMH, via the efficient practice of this reimbursement model, they were able to save up to $98 million and enhance their quality standards by 10%.

Alternative payment methods other than the fee-per-service are not very popular practices. However, physicians are unable to meet their financial requirements. Thus, they are devising ways to incorporate new technologies into their system to speed up the workflow.

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