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Identifying your patients, sorting them by risk, and managing their chronic conditions as a team can help you make the most of value-based care programs.

Fam Pract Manag. 2021;28(6):25-31

This content conforms to AAFP criteria for CME.

Author disclosure: no relevant financial affiliations.

As health care costs spiral higher, more payers are looking to replace the fee-for-service (FFS) system with value-based payment models focused on quality (rather than quantity) of care.

The National Academy of Medicine defines value-based care (VBC) as safe, timely, efficient, equitable, effective, and patient-centered — or STEEEP.1 The University of Utah Health offers a more practical definition, the value equation:2 Value = (Quality × Patient Experience) / Cost.

Value increases when costs go down while quality and patient experience improve. Thus, VBC programs incentivize increased quality (measured through a variety of health metrics) and decreased cost (e.g., keeping patients out of hospitals or emergency departments).

Physicians are often understandably wary of any new payment model. Many of us have been around long enough to hear about the “next great thing” in health care payment reform, only to watch it evaporate while we all keep running on the FFS hamster wheel. But what if we were paid up front to take care of patients and also rewarded for good clinical outcomes? In principle, that's VBC.

KEY POINTS

  • Payers are moving away from fee-for-service payments and toward value-based care (VBC) as a way to curb ever-rising health care costs.

  • Identifying the patients for whom you're responsible, sorting them by risk, and then managing their chronic conditions as a team are keys to succeeding in VBC.

  • There are several pitfalls to avoid in VBC arrangements. If your diagnosis codes are not precise, for example, payers may not adequately credit you for high-risk patients.

VALUE-BASED PAYMENT MODELS

There is not just a single VBC program for your practice to join. Instead, there is a hodgepodge of ever-changing models from Medicare, Medicaid, commercial insurers, and private employers. Unfortunately, sometimes these models come and go (e.g., Medicare's Comprehensive Primary Care Plus program, which is ending this year3), and sometimes their rules and measures are similar, but not quite the same.

It would be simpler and less frustrating if there was a unified, lasting VBC system with consistent metrics. We're not there yet, but a decade of lessons learned is getting us closer.4 However you feel about it, VBC is not going away. In fact, it continues to grow because the goal of improving health outcomes by rewarding clinical quality, prevention of illness, and cost-effective care is appealing to patients, physicians, and payers.

If you're ready to get started in VBC, here are four skills you'll need to succeed and some pitfalls you'll want to avoid.

EMPANELMENT

To take care of your patients, you need to know who they are. Under FFS, we are paid for the patients we see; if a patient doesn't come through the doors of our office or hospital, we are not paid. In VBC, we are paid to care for a set panel of patients, regardless of how many times they visit the clinic.

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