• November/December FPM Focus

    Get Started in Value-based Care — With AAFP Resources

    November 12, 2021, 2:07 p.m. News Staff — Although it’s tempting to think of value-based care as the wave of the future, that’s not — strictly speaking — accurate.

    physician with tablet

    That’s because it’s already here … to stay.

    Based on the simple premise that value grows when care quality and patients’ care experience improve and costs decline, VBC is increasingly being embraced by both public and private payers through programs that incentivize better quality (as measured using various health metrics) and lower cost (e.g., keeping patients out of the hospital or ER).

    The November/December issue of FPM takes a deeper dive into VBC and associated payment models, exploring aspects of this move away from quantity-focused fee-for-service in three different articles.

    The first of these, titled “How to Succeed in Value-Based Care,” outlines four key skills family physicians should cultivate, as well as five pitfalls to avoid.


    In FFS, you provide care services for the patients who walk through your door, and you’re paid based on that interaction. In a value-based system, on the other hand, you’re paid to provide care for a set panel of patients regardless of how often they visit your office.

    Story Highlights

    That means you need to be able to identify and assign patients attributed to your practice to a particular clinician or care team so they can build and maintain a positive patient-clinician relationship. You can optimize your workflow and maximize revenue opportunities by working with your payer to ensure you’re keeping your patient panel up to date.

    Risk Stratification

    Given the truism that a very small percentage of patients account for an outsized proportion of overall care services, it’s to your advantage to determine who those high-risk patients are so you can act to minimize the likelihood they’ll experience costly “downstream” complications. These patients present a unique challenge in that you’ll expend the most resources caring for them, but you’ll also reap the greatest rewards by keeping them healthy.

    Accurately sorting these patients into appropriate risk categories can be tricky, but it’s essential to your success in VBC. Fortunately, the AAFP has resources that can help. Learn about using ICD-10 diagnostic codes that ladder up to hierarchical condition category codes to assign risk scores to patients, which payers combine with demographic data (e.g., patient age, gender, ethnicity, etc.) to assign a risk adjustment factor score. That RAF score, in turn, can be used to predict care utilization levels and associated costs.

    Panel Management

    Skillfully managing your patient panel on an ongoing basis is critical to achieving the good outcomes patients — and payers — are looking for. It’s second nature to routinely monitor HbA1c in the patients with diabetes in your panel who regularly come in for care and adjust treatment if needed, but you need to go beyond that.

    You’ve identified patients in your panel who require extra attention to stay healthy and worked to establish a trusting relationship with them; now it’s time to proactively reach out to those who don’t regularly visit your office to ensure they receive the same ongoing care management as those who do. In most instances, that task can be handed off to other members of your care team.

    Team-based Care

    Whether your practice care team consists of two, three or 20 individuals in a variety of roles, teamwork is key to VBC success. To maximize efficiency, it’s essential that team members be permitted to work at the top of their respective licenses and that nonclinical tasks be handled by nonphysician/nonclinician staff members.

    Utilizing daily staff “huddles” to proactively discuss patient care needs and sort responsibilities into decisions that require physician expertise versus tasks that can be done by other team members can ease the overall workload and ensure work is appropriately and equitably distributed.

    Pitfalls to Avoid

    The article also warned of a handful of potential problems to watch out for. They are:

    1. Meager payments: Don’t let your practice become entangled in a VBC program that doesn’t pay adequately for the care you provide.
    2. Cumbersome data reporting: Data reporting should be accurate, precise and easily surfaced to faithfully reflect your practice’s performance on quality measures.
    3. Poor approach to change management: Implementing a well-thought-out plan that’s supported by staff at all levels is key to creating lasting change.
    4. Misaligned incentives: Incentives to reward performance should be meaningful and appropriate to be effective.
    5. Coding blunders: Precise diagnostic coding is essential to reflect your patients’ true disease burden and ensure you receive the payment you’re due for their care.

    Accurately Capturing Risk

    A second article, dubbed “How to Correctly Capture Patient Risk for Value-Based Care Programs,” digs into the nitty-gritty of using HCC codes to represent patient risk, calling out 10 significant factors to keep in mind.

    1. Duration: HCC codes reset annually, so come Jan. 1 of each year, you’ll need to report all previous diagnoses that remain active. You only need to report each diagnosis once, but not doing so limits your understanding of patients’ care management needs and hinders your ability to respond.
    2. Specificity: A good rule of thumb is that the more specific you can be in coding patients’ diagnoses, the better. Using specific ICD-10 codes better represents patients’ true risk and associated care management needs. Greater specificity also adds weight to the corresponding HCC codes.
    3. Chronic conditions: Many chronic conditions are HCCs, so you’ll want to be certain you address any and all ongoing health conditions in your patients. You don’t need to discuss every diagnosis at each visit, but it’s to your advantage to stay on top of those that may need periodic intervention.
    4. Symptoms: Don’t use symptom codes when a specific diagnosis code can be used instead. Symptom codes don’t risk adjust, but many diagnosis codes do, including some unspecified codes.
    5. Secondary diagnoses: If you address a risk-adjusted diagnosis during a visit for another concern, such as an acute infection, make sure you code for that — and document it —when recording the encounter.
    6. Complications: Code for them! If you don’t code for complications of a patient’s condition that you address during an encounter, you’re basically leaving money on the table.
    7. Medicare wellness visits: A risk-adjusted diagnosis code can be used when coding a Medicare wellness visit if you address that diagnosis during the encounter, but it cannot be the primary reason for the visit.
    8. Undocumented codes: If a patient has a diagnosis that you don’t document, you’re leaving a hole in the medical record and shorting your bottom line.
    9. Diagnosis code specificity tool: EHRs may use different descriptions for the same ICD-10 code. If your EHR has a diagnosis code calculator, use it to ensure you’re coding to the highest level of specificity your documentation supports.
    10. “History of” codes: If a patient’s condition is being actively treated, don’t use “history of” codes for that condition. If a patient is receiving chemotherapy after surgical resection of a cancerous tumor, that condition is still active.

    Clinical Data Registries

    Finally, the article “Put Your Clinical Data to Work With a Registry” explains how registries can be used to organize data from various sources about a particular group of patients, analyze that data and present it in actionable formats, such as electronic dashboards or reports.

    An invaluable population health management tool, a practice’s registry can provide information on which to base clinical or administrative decisions at the point of care, such as identifying high-risk patients in the practice who may require specific interventions to stay healthy.

    National or regional registries offer expanded population management functions and can be used to set benchmarks and compare performance among participants. The information they provide can be particularly useful for value-based payment, risk stratification, strategic planning, quality improvement, and more.

    In family medicine practices, registries are often used for quality reporting in programs such as CMS’ Merit-based Incentive Payment System or various alternative payment models. They can also provide feedback reports to share among team members to foster collaborative approaches to care; track treatments, complications or other aspects of care; and identify patients affected by product recalls or other external factors.

    If you’re considering a data registry for your practice, you’ll find tips from fellow family physicians on steps you can take to get started. Learn what to look for based on how you intend to use the registry, what you can expect to spend in the short and long term, what sort of time commitment you’re looking at to get it up and running, and what training you and your team will need to move forward successfully.

    Value-based Delivery & Payment Hub

    Visit the AAFP’s newly launched Value-based Delivery & Payment Models webpage to learn about available public and private VBP models.

    You also can access a Family Medicine Practice Hack video on strategies to optimize risk adjustment in your practice, and download risk-stratified care management tools to help you identify patients who may benefit from ongoing care management.