As health care organizations in the U.S. move towards electronic systems to manage their patient records, data collection and analysis on health care information has become easier for entities like the Centers for Medicare and Medicaid Services (CMS). As a result of this, trends in patient outcomes and patient health history can provide useful information. This has given way to a new format of hospital reimbursement in health care, which is called value-based care.
VALUE-BASED CARE AND ALTERNATIVE PAYMENT MODELS
Value-based care is a broad term for a reimbursement model for health care organizations (HCOs) in which CMS or other insurance institutions will reimburse based on the quality of care provided and the quality of patient outcomes. This means that providing efficient and quality care to a patient will result in a higher reimbursement for the HCO, while inefficient care will result in a lower reimbursement to the organization. This differs from the traditional fee-for-service model, where providers are reimbursed based on the service provided to a patient, regardless of quality of care or outcome.
One way that CMS has begun to implement value-based care models in the U.S. is by offering certain HCOs the opportunity to participate in Alternative Payment Models (APMs), which is their version of value-based care. There are nearly 100 APMs offered by CMS that organizations can participate in, each of which has different participation requirements and different quality measures by which patient outcomes are measured. The Bundled Payment for Care Improvement (BPCI) Advanced model is a great example of an APM.
BUNDLED PAYMENT FOR CARE IMPROVEMENT (BPCI) ADVANCED MODEL
The BPCI Advanced model is just one example of a value-based payment model, and it’s one that pMD can largely accommodate today. The quality measures tracked by this payment model are:
1. Unexpected hospital readmission for the patient in question within 30 days of discharge
2. Existence of an Advanced Care Plan
3. Quality of care based on a list of 26 CMS-defined Patient Safety Indicators
How are these quality measures reported and tracked? With HCOs' profits on the line, most would not want to participate in a reimbursement model that could lose them money if they’re unprepared. Fortunately, with the BPCI Advanced model, and many of the other models offered by CMS, these quality measures can be completely tracked through electronic means, providing a more streamlined way to submit that information to CMS. The additional work required here, however, would be the time it takes to complete some advanced care planning with your patients, a practice that may not have been standard but has been shown in data to have a positive impact on patient outcomes in health care.
Not only does pMD have the capability to accurately submit claims electronically but we also provide the tools to help organizations better navigate patient care. Our comprehensive platform offers customizations to accommodate the growing needs of practices participating in alternative payments models. pMD’s functionality is constantly evolving to support customers looking to participate in value-based care payment models, improve patient outcomes, and maximize reimbursement.
To find out more about pMD's suite of products, which includes our charge capture and MIPS registry, billing services, telehealth, secure messaging, clinical communication, and care navigation software and services, please contact pMD.