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Are Value-Based Payments Unfair to Some Providers?

If providing healthcare to the aged, the homeless, the unemployed, the uninsured and the educationally challenged can be considered a good deed, current value-based payment models appear to substantiate the adage that no good deed goes unpunished.

That’s the theme of at least three recent studies, the first of which comes from the General Accounting Office (GAO). The GAO is recommending that the Centers for Medicare & Medicaid Services (CMS) take a hard look at the formula it uses to calculate hospitals’ total performance scores under the current Hospital Value-Based Purchasing (HVBP) program.

From fiscal years 2013 through 2017, safety net hospitals — those that serve large numbers of low-income patients — appear to have been inappropriately penalized under the formula, the study suggests, while small rural and small urban hospitals may have been inappropriately rewarded.

Exacerbating disparities?

The second study, published in the Annals of Internal Medicine, concluded that CMS’ value-based payment modifiers affected practices serving higher- and lower-risk patients in ways that have the “potential for Medicare’s pay-for-performance programs to exacerbate health care disparities.”

Eric Roberts, an assistant professor of health policy and management at the University of Pittsburgh Graduate School of Public Health and the lead author of the second study, says things will only get worse for poor people in need of medical care, unless the value-based payment models are modified. And modifying them won’t be easy, he says.

“Risk adjustment is usually inadequate in these programs,” he says, “in part because it is difficult to measure the differences in complexity of patients across providers.”

For example, one key performance measure in the value modifier that’s intended to assess practice quality is hospital admissions for ambulatory care sensitive conditions — conditions, that is, that should be manageable in community-based health care settings, and that shouldn’t require hospital admission. But CMS, he says, fails to consider that disabled and poor patients, as well as those with long-term clinical comorbidities, are more likely to require admission.

It’s virtually impossible, he adds, to provide for all of the relevant predictors of health care use and spending that are needed to separate provider performance from the influences of patient mix. “No amount of risk adjustment is going to completely mitigate the problem in the value modifier,” he says. “Practices that serve sicker and poorer patients are going to get penalized.”

At particular risk

A third study, published in JAMA, concludes that as value-based payment programs “increase in size and scope, practices that disproportionately serve high-risk patients may be at particular risk of receiving financial penalties.”

The study was based on data from CMS’s Medicare Physician Value-Based Payment Modifier (PVBM) Program, a forerunner to the Medicare Access and CHIP Reauthorization Act (MACRA) that penalized or rewarded physicians based on quality outcomes and cost of care. Medical risk was associated with worse quality and higher costs, the study found. Furthermore, it points out, “high social risk” patients may face challenges regarding transportation, food, housing, and security, all of which are likely to affect outcomes, but none of which are measured in Medicare claims.

Closing the gap

There are always going to be disadvantaged patients. And value-based reimbursements that may not properly account for them aren’t going away.

Fortunately, the comprehensive population health management solutions offered by CareThrough are designed to close the gaps that can lead to poorer outcomes and reduced reimbursements.

CareThrough’s navigators offer peer-level support to patients who are overwhelmed by the challenges of daily living. They’re trained to listen carefully and to alert doctors to events and situations that may otherwise go unrecognized. By building relationships with patients, they’re able to collect and convey data regarding changes in health status, nutrition, medication and care adherence, and other potential pitfalls.

Navigators are also trained to coordinate care and motivate patients to strive for successful outcomes.

In short, they help break down the barriers that have long contributed to health care disparities, and make sure that the practitioners who serve high-risk patients aren’t penalized for doing so.

Care Navigators
As healthcare business models evolve, so should care teams.

Patients who are paired with Care Navigators report feeling less anxiety, and an increased ability to self-manage their conditions between visits. And providers report increased job satisfaction from improved efficiency, and knowing their patients have access to care teams, and strategic support.

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Chronic Care Management
With an increased aging population managing two or more chronic illnesses, extending your care teams’ ability to communicate with patients is critical. We take a strategic approach to helping patients chart a path towards their health goals, while self-managing their chronic conditions between clinical visits.

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AI Chatbots
We deliver a robust AI Chatbot solution to help manage and sustain effective communication with patients. Care teams implement the conversational text messages and customize patient communication to deliver high quality care.

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Nurse Care Team Assistants
Adding a qualified Nurse CTA to the care team increases quality of work-life and reduces stress on nurses. The nursing profession is also experiencing an alarming shortage due to increased clerical burdens and burnout.

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Revenue Cycle Management
Transition Revenue Cycle Management into the modern age with a suite of software tools that will transform your billing and coding processes. Transact at lightning speed, with increased transparency and decreased siloes. The QueueLogix software application seamlessly integrates with existing EMRs to ensure the clinical activities and back-office operations are well aligned, monitored and successful.

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Referral Management
Referrals scheduled by navigators in the clinical setting builds long term, patient care integrity across the care continuum. With the authority, along with the provider to search for specialists in network, navigators assess their schedules, and ensure appointment compliance.

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Scribe Services
There’s a reason why we’re the nation’s most frequently used scribe company: we offer professionally trained medical scribes to meet the specific needs of our clients. We offer a variety of scribe programs, as well as technology and personnel solutions that address revenue cycle management, the transition to value-based care, and more through our HealthChannels family of companies.

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