Trouble Ahead for Some Medicare Shared Savings Program Providers

Trouble Ahead for Some Medicare Shared Savings Program Providers

A healthcare storm is brewing between CMS and Medicare Shared Savings Program providers who have not engaged with the agency’s value-based care efforts, an essential step in readying for the new “Pathways to Success” initiative.

Just like stubborn homeowners who don’t heed the hurricane-evacuation orders of emergency officials, healthcare providers who have not yet aligned with CMS’s graduated program targets are living dangerously. And, as with those who disregard calls to vacate and risk their lives by not adapting to the hazardous situation at hand, the end result for these providers could be equally calamitous.

This is not to say that providers who haven’t kept up with CMS’s value-based agenda are stubborn.  In fact, these physicians are more likely to say that they’re just too busy and simply don’t have the time to align with CMS’s value-based initiatives. One doctor might care for 300+  fee-for-service Medicare patients, and even if his/her practice uses an EMR, they are not managing patients from the perspective of population health requirements.

It’s evident that a lot of these providers are focusing their attention on clinical operations and the mandatory reporting needs for MIPS while overlooking the business side of their practice.

The result?

Many are struggling in our new value-based world. Providers are so bogged down with the day-to-day work of seeing patients that they are not adequately preparing themselves to continue as providers in the current march towards value-based care. Getting in line with CMS’s value-based goals isn’t optional, it’s mandatory.

In the future, providers who do not adhere to the tenets of value-based care are not going to receive the same level of reimbursements realized currently, it will be harder to make up shortfalls, and there may be penalties for non-compliant reporting. Non-adherence may result in poorer reported and measured outcomes, and the provider’s publicly available rankings will drop. Patients and ACOs will likely take note of these ratings and avoid the provider.

As the effective date of the Pathways to Success initiative comes closer, both CMS and providers must assume more responsibility to facilitate adoption of value-based initiatives. However, the agency as well as providers should understand that change will not occur overnight.

Even though CMS has taken steps to support the adoption of value-based care – like backing practice transformation networks (PTNs) that help providers to change priorities, strategize to manage their patients under these new market place changes, use electronic health records, incorporate care coordination, and include remote patient monitoring – providers must also bear responsibility for ensuring a smooth transition and work proactively to align with these programs. Otherwise, much like the homeowners stranded on their rooftops after a hurricane strikes, providers will likely wish that they had taken steps to prepare before adversity befalls them.

Perhaps the most significant area where providers need to educate themselves is capturing patient co-morbidities and family history in the medical record and making sure that this data is communicated to the payer/CMS to accurately risk stratify the patient. Some physicians simply don’t realize how vital this step is to their operations. And in today’s value-based world, not being vigilant about including this information in every claim file as a communication tool may have negative repercussions over time.

For example, if a patient was treated for a chronic condition in 2016 and is actively being treated for the same condition in 2019, it must be coded on at least one claim per year. Without doing so, the patient’s risk score falls because CMS doesn’t know whether the patient still has the condition or whether it’s been resolved.  The aggregated benchmark that is influenced by these co-morbidities will also fall in time, affecting the opportunity to participate in shared savings in support of the better care and outcomes that the provider has tried so hard to influence.

Quite simply, many providers still need learn how the value-based care world operates. That is, they must understand risk scoring and coding and how these activities align with benchmarking, and ultimately, shared savings. Providers should not rely on CMS alone to provide additional resources; instead, they should seek help and advice from subject matter experts to keep up with the changes and reprioritize their efforts and allocation of resources.

So, like those who didn’t heed the words of emergency officials ahead of a hurricane, some physicians may not realize the magnitude of the storm ahead of them. The good news for them, however, is that the full brunt of the value-based-contract storm hasn’t hit yet, and there’s still time to get help.