Tag: value-based care

Key metrics for value-based care

By Vatica Health | November 18, 2024 | Value-Based Care

Value-based care (VBC) is designed to incentivize providers to improve outcomes in a cost-efficient manner. In other words, payment and quality of care are inextricably linked. Understanding how VBC payments and penalties are calculated can help you better prepare and operationalize your VBC action plan—no matter where you are on the adoption timeline. In this article, we discuss how quality and cost intersect to help providers optimize practice performance in a VBC world.

Key metric 1: Quality

Two of the most critical components of any VBC arrangement are risk adjustment and quality reporting. This is because success in VBC depends on accurately assessing the clinical needs of your population and reporting these needs so that your payments will be sufficient to deliver appropriate care.

The challenge is that risk adjustment and quality reporting are labor-intensive and predicated on a complex set of rules, which frequently become a stumbling block for practices. Because of the complex payment methodology associated with risk adjustment, appropriate coding specificity is needed to accurately report chronic conditions. Without this specificity, plans and PCPs may end up with artificially low patient risk scores, resulting in insufficient funds to deliver adequate levels of care.

Similarly, PCPs must adhere to the reporting standards for quality gap closures. Deviation can result in sub-standard outcomes. For practices that lack specialized coding and quality technology, as well as properly trained staff, keeping up with these activities is a significant challenge.

Other measures relate to preventive health, such as ordering mammograms or colonoscopies. These routine activities are critical metrics for the health plan. Whether they’re process, outcome or preventive health metrics, it’s important that you understand all measures in your VBC programs and how they impact your financial performance.

Whether they’re process, outcome or preventive health metrics, it’s important that you understand all measures in your VBC programs and how they impact your financial performance.

Data for some measures come from standardized patient surveys such as the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) or the Health Outcomes Survey (HOS). Health plans use these surveys to understand how patients feel about access to care, their perception of the quality of care at their physician’s office, and how they feel about their overall health. The questions are not related to the patient’s health insurance benefits; instead, they correspond to the care they receive from their physicians. It’s obvious how physicians influence the responses and why health plans want to partner with physicians to improve scores.

How providers are compensated

Quality of care compensation typically will be paid on a per-patient basis. For example, every time a hemoglobin A1C is ordered or you get a patient’s LDL below 100, the health plan will make a certain payment, usually on a quarterly or monthly basis.

Other VBC models involve a unique set of quality measures. Five or 10 may be needed to achieve a minimum threshold. Or seven out of 10 quality measures are needed to earn a bonus. This is typically the way quality measures are used in a model. A minimum is needed to qualify for a bonus. The bonus dollars associated with achieving a result higher than the minimum can be paid out on a per-patient basis or on the population of patients attributed to a given provider.

Key metric 2: Costs

Costs can be measured in several different ways:

  • Medical loss ratio (MLR)
  • Medical expense ratio (MER)
  • Medical claims ratio (MCR)

All these methods involve taking medical expenses for your patients and dividing them by the premium that they’ve received for that patient. This is the risk-adjusted premium. Another way that it’s measured is by looking at the absolute cost per member—often expressed as per member per month (PMPM). Health plans take the claims expense for attributed patients and divide it by the number of patients you have. This produces a PMPM, regardless of what the measure is.

A common model uses hospital admissions, readmissions and ER visits. Those are big drivers of cost for a health plan. Sometimes, instead of using medical expense ratios or claims PMPM, plans will drive a penalty or bonus program from some of these key utilization metrics. Sometimes, those metrics will be expressed per 1,000 patients so plans can normalize that data. If your practice has 500 patients with a health plan, and there are 10 hospital admissions that month, you might see the metric described as “20 admits per 1,000.” The health plan is creating a standard across all practices so that they can compare results among practices and benchmark how each is doing. Note that some of these programs are purely based on quality, without any cost component.

A study by analysts at Harvard and Humana found Medicare Advantage members treated by doctors in advanced VBC models had 5.6% fewer hospitalizations and 13.4% fewer emergency department visits.

VBC cost vs. quality metrics

It’s important to understand both the quality and cost metrics and any relationship between them. In some cases, PCPs may need to achieve a minimum quality standard before earning any quality or cost bonus. In other cases, there are no minimum thresholds for quality; PCPs are paid as certain benchmarks are met. It matters because more and more of a PCP’s compensation is going to be tied to VBC. CMS expects all Medicare payments to go through value-based models by 2030. Those payments or penalties are calculated by using these metrics. It’s critical to understand what each of the metrics is, how the penalties or bonuses are calculated, and how you are doing today relative to the program’s maximum penalties or bonuses.

Operationalize your VBC plan

Download the full VBC white paper to learn the key action items to develop and implement a VBC program and the steps needed to improve an existing one.

Maximizing quality of care. Minimizing admin load.

By Vatica Health | July 12, 2024 | Risk Adjustment

Effective risk adjustment drives value-based care performance and promotes fairness and equity in the Medicare Advantage (MA) program by ensuring that payments to health insurance plans and providers reflect the health status and needs of the patients. 

The keyword here is effective. For risk adjustment to deliver on its purpose and its promise, all parties involved—patients, providers and payers—must be coordinated and aligned. The trouble is, legacy programs, such as Health Risk Assessments (HRAs) completed by in-home assessment vendors, remain disconnected from treating providers. While HRAs can be a helpful tool in identifying active conditions, diagnoses captured in HRAs are often not recorded in a subsequent medical visit. Detached programs and practices can undermine the purpose of risk adjustment, increase the risk of non-compliance with evolving regulatory requirements and fail to adequately support and incentivize providers in their transition to value-based care (VBC).

The modern healthcare ecosystem is increasingly complex. Risk adjustment programs that exclude the Primary Care Physician (PCP) are inefficient, create provider-patient friction and amplify risk. Physicians and their teams need a risk adjustment solution that makes coding and documentation easier and leads to high-quality outcomes for their practice and their patients.

Here’s how Vatica Health’s one-of-a-kind risk adjustment and quality of care solution can complement current coding and documentation processes and enhance risk adjustment without overextending staff or sacrificing precious time and resources. 

1. Prioritizes coding accuracy and completeness


Why it matters

Accurate coding is the backbone of effective risk adjustment, ensuring risk scores are calculated correctly and reflect the true health status of enrollees. HRAs, typically performed in-home by vendors on behalf of MA plans, can lead to inflated HCC scores and compromised care.


How Vatica delivers

  • Point-of-care integration: Vatica works at the point of care and proactively surfaces the most appropriate and up-to-date conditions for PCPs to validate. Physicians can focus on their patient interaction, knowing they have a complete and accurate picture of the patient’s conditions.
  • Holistic data collection: Unlike other solutions, Vatica collects and analyzes data from various sources, as well as unstructured data, including consult notes and medical images, offering a more comprehensive picture of a patient’s health. No need for PCPs to connect the dots between various systems and sources.
  • Clinical review: With Vatica, 100% of patient encounters are reviewed by clinicians, such as RNs with advanced coding certifications. This ensures accuracy, completeness and compliance—and offers peace of mind for PCPs.


2. Works with and for providers


Why it matters

Any risk adjustment solution that providers adopt needs to reduce friction, not add to the already taxing administrative load. A flexible and user-friendly solution that meets PCPs where they are ensures effective and robust use, promoting better outcomes for everyone.


How Vatica delivers

  • Provider-centric approach: Comprehensive pre-encounter work performed by Vatica clinicians arms providers with the most clinically relevant information to deliver the highest quality of care during patient visits. Providers remain at the center of care to diagnose, document and follow up.
  • Workflow compatibility: Vatica’s EMR-independent technology works within existing workflows, meeting providers where, how and when they work. 
  • Administrative support: The unique Vatica model includes expert clinician coding support, allowing PCPs more time to deliver high-quality care and assuring that coding and documentation will be accurate, complete and compliant.
  • Payer-agnostic: Vatica is payer-agnostic. Clients include most national health plans and many regional plans. 


3. Supports better outcomes for patients and PCPs


Why it matters

Accurate risk adjustment is a cornerstone of value-based care. Continuing to rely on legacy programs like HRAs and chart reviews that might not reflect the true status of health—and can lead to inflated HCC scores and inaccurate risk-adjusted payments—flies in the face of VBC principles and sets providers back in their journey.


How Vatica delivers

  • Help in identifying care gaps: Vatica flags open HCC coding and care gaps for PCPs to address during encounters. Real-time clinical data assists providers in addressing HEDIS measures during their interaction.
  • Accurate VBC benchmarking: Vatica empowers providers to make the PCP visit the foundation for VBC benchmark accuracy. PCPs can deliver continuous, more effective care and build stronger patient relationships. 
  • Revenue opportunities: Vatica helps PCPs earn additional revenue through reimbursable visits, health plan incentives and enhanced VBC performance.


Better risk adjustment benefits everyone

Vatica Health’s Best in KLAS® risk adjustment solution is designed to help health plans, providers and patients achieve better outcomes, together. By increasing patient engagement and wellness, improving coding accuracy and compliance, and helping identify and close gaps in care, Vatica helps ensure that everyone benefits.

How complete and timely data exchange can improve VBC outcomes

By Vatica Health | December 13, 2022 | Value-Based Care

Doctor typing on a laptop

As an old saying goes, “timing is everything.” In value-based care (VBC), that’s especially true—particularly when it comes to data exchange. Timely data exchange is essential. It provides greater visibility into a patient’s overall health during a face-to-face encounter, enabling providers and payers to deliver the best care with the appropriate resources.  

There’s no question that VBC thrives on accurate and timely data. Data identifies target patient populations. It spots risk factors and care gaps. It can highlight problem areas and drive appropriate interventions. And when leveraged effectively, it improves efficiency, measures progress and ultimately enhances VBC performance.  At the end of the day, having a 360-degree view of current patient information is essential to making sense of a patient’s health and making the best care decisions at every encounter.

Despite the importance of leveraging actionable data at the point of care, there are some formidable stumbling blocks. Relevant clinical data is often siloed – stored in different systems that do not communicate with each other. Payers, providers and pharmacies maintain separate databases that are not reconciled. This can lead to conflicting information, confusion and ultimately, subpar care. 

There has been a lot of progress to enhance integration and interoperability among various EMRs, stakeholders and systems — but we are still in the early innings. A lot of healthcare data is contained in unstructured formats or trapped in an EMR that doesn’t integrate with other databases. A readily available single source of truth with all relevant clinical information to inform a patient encounter and real-time decision making is rare. Therefore, providers and payers unknowingly make decisions based on incomplete and conflicting information. This impacts care and outcomes and leads to the inefficient use of resources.    

While current and timely data exchange is critical, it’s not a panacea. There has been a lot of progress in healthcare technology, such as artificial intelligence and natural language processing, but nothing replaces the judgment and experience of a trained clinician. A lot of important patient information remains trapped in unstructured formats such as images and physicians’ notes, which technology alone doesn’t sufficiently address. In addition, complex algorithms are rendered useless if the underlying clinical data is inaccurate.

The holy grail is to arm specially trained clinicians with powerful tools to curate all relevant patient information at the time of the encounter and leverage technology to supercharge, not replace, physicians. The combination of the right data, the right clinical resources, at the right time would help drive the most efficient and informed patient visits, lower costs, enhance care and drive practice performance in VBC and other risk sharing arrangements.

How Vatica can help

Vatica Health offers a unique model that pairs expert clinical teams with cutting edge technology at the point of care.  This innovative combination produces a powerful biproduct – sensemaking machines that help our clients wade through a sea of data to garner insights and make better clinical decisions. 

 Vatica’s licensed nurses curate all relevant clinical data to inform comprehensive visits. This information is conveniently documented and provided to the PCP prior to the visit. Only vetted HCC codes and care gaps are presented so PCPs can make the most of their time with patients. Health plans purchase the Vatica solution and make it available to PCPs in their network at no cost to help improve coding and documentation for risk adjustment. A key component of VBC, risk adjustment ensures that risk bearing entities are properly compensated and that adequate resources are available to care for patients, based on their specific conditions and healthcare needs.