• Value-based Delivery & Payment Models

    Navigating today’s shifting payment environment

    It’s clear that volume-based, fee-for-service (FFS) care doesn’t adequately support the comprehensive, continuous nature of primary care, and it doesn’t keep costs in check. Value-based care (VBC), by contrast, is comprehensive and longitudinal, prioritizing quality and outcomes over quantity of services provided.

    Value-based payment (VBP) promotes that level of care by holding physicians,  clinicians, and care facilities accountable for quality and cost through shared financial risk. VBP uses alternative payment models or pay-for-performance arrangements to reinforce health care decision-making by tying compensation to performance measures.

    How can you benefit? If you’re in independent practice, the chance to earn shared savings or other incentives directly impacts your bottom line. If you’re an employed physician, it’s a safe bet your employer is considering or already using performance on quality and care utilization measures to determine your compensation. Learn more about available public and private payment models and determine what could work for you and your care team. 

    Value-based Care:
    FPM Covers the Basics

    Delivering high-value, patient-centered care―as a family physician, that’s simply what you do. Being appropriately paid for delivering that care should be just as predictable. That’s the premise behind value-based payment and care delivery.

    The November/December 2021 issue of FPM focuses on value-based care (VBC) and can set you up for success.

    To succeed in VBC, you need to cultivate key skills and avoid certain pitfalls. That means knowing how to identify your patients, sort them by risk, and manage their chronic conditions as a team. You’ll also need to ensure you don’t settle for meager payments or lackluster incentives, manage change poorly, or let suboptimal data reporting or coding missteps sidetrack your efforts.

    Paving the Path to Value: Care Management and Coordination

    Providing appropriate care management and coordination services to high-risk/high-needs patients will be key to your success. This FPM journal supplement can help you implement care management and coordination in your practice.

    Accountable Care Organizations

    Accountable care organizations (ACOs) can comprise almost any combination of physician groups, practice networks, hospitals, and other facilities that agree to share responsibility for the quality, cost, and coordination of care for a defined patient population. ACO programs have been piloted by the Centers for Medicare & Medicaid Services (CMS) and private payers. To achieve shared savings, participants must meet designated quality and performance metrics. Primary care physician leadership can be key to ACO success.

    Physician Payment & Risk

    To succeed in any care model in which payment is tied to achieving cost and quality benchmarks, it’s essential for primary care physicians to understand and be comfortable with the type of risk they are accepting in a payment contract. It’s also critical that they have a clear picture of their patient population and that population’s health risks so they can offer appropriate preventive and chronic care management services to optimize health outcomes.

    CMS Primary Cares Initiative

    The CMS Primary Cares Initiative includes five new APM options for primary care physicians under two paths: Primary Care First (PCF) and Direct Contracting (DC). The PCF path, currently offered in 26 regions nationwide, features a multi-payer system designed to create opportunities for practices ready to take on more risk through payments based on utilization outcomes. DC model options aim to reduce cost and improve quality of care for beneficiaries in Medicare FFS.

    Comprehensive Primary Care Plus

    Comprehensive Primary Care Plus (CPC+) is a multi-payer practice transformation model that offers primary care practices an opportunity to receive enhanced, more flexible payment and participate in a robust learning community to better meet patient needs. This CMS-led advanced APM provides upfront payment along with technical assistance. CPC+ offers two tracks: Track 1 for practices building capabilities and Track 2 for those already delivering advanced primary care.

    Direct Primary Care

    The direct primary care (DPC) model offers the family physician a meaningful alternative to FFS insurance billing, typically by charging patients a monthly, quarterly, or annual fee. This fee covers all or most primary care services, including clinical and laboratory services, consultative services, care coordination, and comprehensive care management. In DPC arrangements, patients gain more time with their physician, and physicians can avoid costly overhead.

    Medical Home

    The medical home offers an approach to providing primary care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective. Care delivered in this setting leverages the partnership between patient and personal physician and, when appropriate, involves the patient’s family. Transitioning to a medical home requires time, commitment, and physician leadership, but it can position a practice to better respond to a changing health care landscape and, ultimately, benefit patients, care teams, and the practice’s bottom line.


    Additional Resources

    Hierarchical Condition Categories Reveal Patient Complexity 

    Hierarchical condition category (HCC) coding is a risk-adjustment model designed to convey the full picture of patient complexity. HCC coding uses ICD-10 codes to assign patient risk scores that, together with demographic factors, are used to determine their risk adjustment factor (RAF) score and estimate future health care costs. RAF scores are also used to risk adjust quality and cost metrics.

    Learn how using team-based strategies can optimize risk adjustment in your practice with this Family Medicine Practice Hack video.

    Here's How to Get Started With
    Risk-Stratified Care Management

    When payment is tied to your performance on health care quality and cost metrics, understanding the patients you’re responsible for managing can set you up for success. In risk-stratified care management (RSCM), patients are assigned a health risk status, and care team members collaborate with them to develop and implement an individualized care plan.

    Need help getting started? Download the free RSCM rubric and scoring algorithm to identify patients who may benefit from ongoing care management.