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Care Coordination: The Key to Surviving in a Value-Based Reimbursement World

by Lynn Guerrant BSN, MS on July 3, 2018 at 12:35 PM


Defined by Professor Michael Porter of Harvard Business School, value is a function of outcomes and costs. Therefore, to achieve highvalue healthcare, providers must deliver the best possible outcomes in the most efficient way.

The outcomes should matter from the perspective of the individual receiving healthcare and not the provider’s process measures or targets.  Value-based care transitions the focus of reimbursement from the quantity of services provided to the quality of the services provided. However, accurately measuring quality continues to be an area of growing concern for healthcare practitioners. 

At the purest level, value is equated with the health of the patient, based on the care provided to achieve and maintain a constant state of well-being.  When providers receive “quality report cards” from payers where key clinical metrics are scored, many providers’ primary response is challenging the data integrity of the report card.

For instance, metrics like “HbA1C < 9” are purported to measure the effectiveness of provider treatment of diabetes.  However, how can a provider be measured by a patient’s HbA1C being below nine when their patient lacks the financial ability to pay for the prescription to achieve control over their diabetes? Or where in the report card is the patient’s financial inability to buy healthy foods taken into consideration?

Primary care providers are being held accountable for the total cost of the patients attributed to them, and it is no surprise that they feel like that have control when these external factors are not being taken into consideration. While some of these subjective metrics are still going to have providers scratching their heads, there are other ways to make strides to optimize reimbursement.

Care Coordination: Start by focusing on hospital readmission

Beginning in 2018 with the Merit-based Incentive Payment System (MIPS) scoring model, cost of care will count for 10 percent of a provider’s overall score. Thus, embracing the concept of serving as a patient-centered medical home provides the framework for collaboration and care coordination, reducing unnecessary costs and duplication of services. But care coordination is not cheap and many providers do not have the staff to allocate to this service.  A key starting point for providers, then, is to implement a robust transitional care management program.

Hospital readmission rates within 30 days of discharge is a metric tracked by all payers. By focusing on patients discharged from an inpatient facility, providers can begin to impact this important metric.  This care coordination is reimbursed by the majority of payers as long as the mandatory requirements for billing this service are satisfied.  Implementing this key care coordination program will quickly identify high cost-high utilizers and allow providers to individualize treatment that will engage payer and community resources to impact this behavior.

Succeeding in a value-based environment requires the acceptance that the responsibility for the entire healthcare of their respective attributed patients belongs to the primary care provider. As such, investing in care coordination is essential and controlling utilization of services is vital to cost containment.

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This post was written by Lynn Guerrant BSN, MS

Lynn Guerrant is the Director of Operations at Intermedix. In this role, Lynn managers operational policies within multiple medical practices. Prior to joining Intermedix, Lynn was a CHACC Program Director at AccessCare, where she was responsible for the administration of the Center for Medicare and Medicaid. Lynn obtained her bachelor's degree in nursing from the University of Mississippi and her masters degree in healthcare administration from the University of California, Berkeley.

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