Medicare Reimbursement Declined – 5 Essentials for Success In The New Healthcare World

One of the many challenges physicians are facing this year is transitioning from volume-based payment to value-based payment. Medicare Access and CHIP Re-authorization Act also known as MACRA replaces the current Medicare reimbursement schedule, fee-for-service, with a new value-based care framework that’s focused on quality, value and accountability. This transformation is the most important industry-wide effort that it will impact millions of healthcare providers across the nation.

MACRA offers two reimbursements path models, Advance Alternative payment Models (APMs) or the Merit-based Incentive Payment System (MIPS). The MIPS model is an incentivize model which consolidated three existing Medicare quality program into one. Many independent medical practice will opt for MIPS due to its incentivized benefits and potential to increase net revenue through payment adjustments, that in some cases, reward value in primary care rather than volume.

With such dramatic change, independent medical practices are asking: What can we do to thrive under this new value-based care equation?

In this article, I present some tips to aid the solo and small healthcare practices on how to better utilize information technology tools under value-based care framework. In addition, we look at how to improve financial results, while reducing overall costs.

5 Tips for Small Independent Practices to Succeed

1. Robust investment in analytics to predict re-admissions.

Understanding the patterns in your data allows you to act on trends before they become cost-draining issues.

For example, by analyzing data information about patients being treated. Small practices can more readily flag patients that are likely candidates for readmission. Then tailor patient engagements and interactions specific to these patients. From there, make the quality improvements that can lead to better clinical outcomes. The cost of investing in a population health management solution can help to generate higher savings overtime.

Remember, the only way to report on those outcomes – and get paid for the service you provide – is through quality data. Look to IT solution such as a population health management system to help provide the quality data your require.

2. Empower Patients to Take Control of Their Own Health

Independent Health practices should focus on the specific attributes of their communities to move toward a quality driven model. Strategies that personalize delivery and empower patient’s to take better control of their own health are the most likely to succeed.

For example, a physician who serves a predominate Hispanic population may want to consider developing diabetes prevention programs. These programs could focus on aiding in limiting the spread of the disease.

Development of such programs can help small independent practices better define information technology tools. For example, data-driven tools. These tools provide insight on cost and quality metrics, and provides the data needed to make care decisions that are consistent with effective clinical practice.This may improve service delivery and greater value-based outcomes.

3. Deliver continuous access to mission-critical systems and data

No matter what size your organization is, no organization can afford downtime. In healthcare, system failures cost more than money. They can cost lives. When the flow of data is disrupted, the effect is viral and impacts patient health and safety, internal processes, and revenue.

High availability is no longer a nice-to-have, it’s a must have. Across all industries, High Availability (HA) is measured in nines. “One nine” refers to 90% systems uptime, “five nines”, a standard reference point, refers to 99.999% uptime. Downtime that occurs during peak patient care hours will have a larger impact to your organization than downtime occurring in off-peak hours.

For high availability configurations your IT needs to ensure there are no interruptions in flow of data and that patient and administrative functions are being performed according to standards. High availability for healthcare should:

  • Allow for scheduled system maintenance and upgrades without disruption in service
  • Respond to unplanned system outages
  • Scale to meet your volume requirements
  • Reduce the burden on your internal IT resources
  • Employ fault-tolerance and automated failure detection
  • Provide 99.999% uptime

Solo and small healthcare practices that have previously regarded downtime as inevitable, or necessary evil, must adapt to increase availability requirements. As the volume of information exchange across increases – so will the amount of revenue lost per second of downtime.

4. Form alliances to help meet requirements and maximize payments

A great method to help maximize payments under CMS payment policy is by forging an alliance with other healthcare organization. The right alliance may help with meeting requirements from payers and patients for delivering quality.

Given the central role that technology plays in today’s health are environment, carefully consider the IT implications of any new alliance before committing to the partnership. Considerations that can assist in ensuring a successful clinical partnerships include:

Put a premium on sharing – Many organization will have different technologies that need to work together. Invest in integration platforms that make connections nearly seamless, which can streamline and simply information sharing.

Insist on interoperability. Many organization have invested in EHR or EMR technology. Forcing alliance partners to change technologies for the sake of uniformity only creates more confusion and disruption. Implementing an integration model that allows information to be meaningfully used in different clinical systems will increase interoperability.

5. Secure your data

Healthcare data is the new frontier for aggressive hackers seeking an easier and more lucrative way to conduct identity theft. The estimated cost of a healthcare breach is quantified as $200 per-patient record. This does not include lost business and financial resources. Keeping your applications, patient data and system secure will aid in maximizing your payments under CMS.

When it comes to healthcare data, you can never be too secure considering the facts. Here are steps you can take now to help you practice better secure your data:

  • Recognize that changes in policies must come from the top levels of an organization
  • Assess the 5 Rs in your security strategy: risk, redundancy, replication, recovery and responsibility.
  • Review and update your HIPAA compliance regularly. By achieving HIPAA compliance you will also increase your cybersecurity posture.

Between diminishing reimbursements and the transition to value-based care, sole and independent healthcare providers face ever-increasing pressure to reduce healthcare delivery cost. In order to protect margins business operations need to be manage more efficiently

Value-based Care Equation

The Holy Grail to achieving optimal value-based care, is to find less expensive ways to provide optimal care in a lower cost environment that is also accessible. More Specifically, in order to thrive in the era of value-based reimbursement, small independent health care organizations will need tools that allow them to measure their outcomes.