Implementing value-based payment models requires changes to revenue cycle processes, including a greater focus on making sure claims reflect all services performed.
Participation in accountable care has significant implications not only for care delivery systems but for the revenue cycle. Both providers and health plans can take steps to ensure that the transition to population health management is financially tenable for hospitals and health systems.
Underscore Accuracy
Efficient and accurate revenue cycle processes are even more important under accountable care, says Blake Allison (pictured at right), COO of the Baylor Scott & White Quality Alliance, the accountable care organization (ACO) for Dallas-based Baylor Scott & White Health.
The Baylor Scott & White Quality Alliance (BSWQA) serves 450,000 lives, mainly in commercial contracts. The ACO is comprised of more than 5,700 primary care and specialist physicians and 49 hospitals, and more than 95 post-acute care facilities and other healthcare stakeholders throughout north and central Texas.
BSWQA operates mainly under shared savings contracts; if the ACO achieves certain performance and outcomes targets, it shares in the resulting cost savings.
Given all the aspects of care that reflect performance, which affects revenue under shared savings, tracking services provided using claims data is critical. Claims therefore must reflect all services performed, Allison says.
“What we’re finding now is—because so much of our data is claims-based, and so many of our metrics are based on claims—the accuracy and completeness of the claim that we send to the payer is even more critical in our new environment of accountable care,” says Allison, who presented on the topic of accountable care at HFMA’s 2017 Revenue Cycle Conference in October.
“If we don’t appropriately account for a test that we did, and send the claim off, it can have ramifications for our performance.”
For example, targets in some of BSWQA’s contracts require more than 80 percent of diabetes patients to have completed an A1C test. At one point, the ACO discovered that several large physician groups were not documenting the test on claims sent to payers. Consequently, BSWQA was at risk of losing more than $1 million in shared savings revenue if the target was inadvertently missed because the performance did not reflect the required testing.
The example demonstrates the need for providers to build effective communication channels with revenue cycle partners, including physician offices that send claims to payers. BSWQA has teams composed of analytics and network experts, along with practicing physicians and other clinical leaders, who work with revenue cycle staff at physician groups to identify issues that may result in inaccurate claims and to then develop solutions.
Solving the A1C test issue involved educating physicians on the importance of documenting all services performed on the patient and then ensuring that the claim reflects those same services. In this way, key performance elements are accurately captured, Allison says.
Payers as Partners
Another consequential impact of accountable care is the restructuring of the traditional health plan-provider relationship into more of a partnership.
To help smooth the transition to accountable care, plans and providers should develop a set of guiding principles that include aligned objectives, says Brigitte Nettesheim (pictured at right), vice president of joint venture markets in the Clinical Services & Joint Venture Markets division for Aetna. For example, Nettesheim says the sides should agree to focus on how to improve the health of the community first, before deciding on the terms of the contract. “What’s right for the consumer? And then we figure out the financial model after that,” she says.
Aetna has value-based contracts with more than 500 ACO arrangements across its commercial and Medicare lines of business, including with large health systems such as Mt. Sinai Health System in New York City, Memorial Hermann Health System in Texas, Centura Health in Colorado, Vanderbilt Health Network in Tennessee, and Wakemed Health & Hospitals in North Carolina.
Because ACOs represent a newer approach, there will be natural business conflicts between provider and health plan. Having a documented set of guidelines will help to navigate disagreements, Nettesheim says. “It’s important to be able to refer back to those guiding principles and make decisions based on those,” she says.
Allison says the key to forming a strong business relationship is transparency, especially in the context of how to meet the goals that are stipulated in the contract. For example, health plans and providers have to agree on which financial and quality metrics to use for the ACO.
“Payers want to measure everything that’s important to a payer, and understandably so,” Allison says.
However, because physician performance drives the performance of the ACO, metrics should reflect what physicians can actually deliver based on their capabilities and workflow, for example. “We spend a lot of time working on aligning the metrics all the way through from the contracts to the doctors,” Allison says. Utilization metrics such as emergency department visits per 1,000 lives as well as key clinical outcome metrics (e.g., blood pressure in control, breast cancer screening, etc.) that may require clinical reporting from the ACO, need to be integrated into the overall performance discussions that take place between the health plan and the ACO.
Providers also need claims data to determine patient utilization outside of the ACO network. It is important, for example, to evaluate high costs of care that are associated with patients who are high users of care and often find themselves making an unnecessary trip to the emergency room. However, payers are often reluctant to provide this type of data.
For BSWQA, that expectation is non-negotiable. “That’s an easy conversation for us,” Allison says. “There’s not going to be a relationship with the Quality Alliance if you do not give us every ounce of claims data that ever happened on one of our patients.”
Any expectations regarding data must be explicit from the beginning of the relationship, Allison says.
Nettesheim says Aetna views part of its role as helping providers establish the infrastructure that is necessary to participate in population health management. That effort includes helping the provider obtain the data access and robust reporting capabilities that are required to track and monitor performance and communicate that information to the payer, whether a commercial insurer or employer.
“Our goal is to help with that transition,” Nettesheim says.
Because providers are at different stages in their abilities to manage populations and accept financial risk, Nettesheim says health plans should be willing to implement contracts based on the provider’s readiness for value-based models. For example, Nettesheim says an initial contract may involve gainsharing only; that may transition into a contract with some financial risk, which gradually increases as the provider gains expertise in managing populations.
This approach allows time for providers to make the necessary investments in the leadership and other infrastructure that is necessary for population health management. It also gives the provider and health plan time to learn how to work together, she says.
“This is a staged approach so that everyone is in lockstep and the providers will be successful, both financially and from an outcomes perspective,” Nettesheim says.
A fundamental part of a successful transition to population health management is planning. Allison says a good time frame is 18 months. “If you think you’re going to do value-based care in 2019, then in my view you’re already behind if you’re not in active dialogue with your payers,” he says. “You’ve got to commit to a time frame that is reasonable.”
Karen Wagner is a freelance healthcare writer based in Forest Lake, Ill.
Interviewed for this article: Blake Allison, COO, Baylor Scott & White Quality Alliance, Dallas; Brigitte Nettesheim, president, joint venture market operations, Clinical Services & Joint Venture Markets, Aetna, Hartford, Conn.
This article is based in part on a presentation at HFMA’s 2017 Revenue Cycle Conference.
