Insights20 Value Based Care Basics
Sunday, November 22nd, 2020
The COVID19 pandemic uncovered the many benefits of Value Based Medicine, including better outcomes and higher revenue. But Value Based Care comes with its own challenges.
In this video, CareOptimize Chief Commercial Officer Kegan Williams outlines:
– VBC Basics
– How VBC Fits into Today’s Market
– CareOptimize: Revolutionary VBC Technology
– How VBC Can Benefit You

 

 

What to Consider When Transitioning to Capitation Payments
Thursday, November 19th, 2020

In view of the COVID-19 pandemic, more providers are contemplating moving to capitation arrangements. The decision cannot, however, be made lightly; the risks and complexities of lump sum payments need to be carefully addressed by provider organizations before any decision to switch is made.

Organizations need to recognize the effect the restructuring of the healthcare industry would have on capitation payments. There is a strong financial opportunity for physicians to scrutinize hospitalizations and emergency room admissions and offer higher care levels to patients. This could be a challenge for consolidated health networks that involve hospitals and clusters of doctors. To offset fixed and variable costs of inpatient treatment while still financing alternate care facilities, these organizations may have to determine resource distribution.

Specialist benefits under capitation payments continue to be discussed. Organizations aim to place the primary care provider at the forefront of a healthcare team in alternative payment structures, and capitation payments definitely urge organizations to do so. However, under the alternative payment arrangement, specialists do need to be accountable for total care costs.

Under capitation fees, health services would need to consider how to handle financial risk. The success of capitation payments is jeopardized by complications, debilitating illnesses, and other avoidable problems. But with stop-loss insurance and payment allocation for high-cost products, such as specialty medications and equipment, providers can minimize the effects of these problems.

This update is provided by CareOptimize. We provide healthcare management consulting services and products, managed care solutions, value-based expertise, Nextgen EHR utilities, MIPS consulting, and more. CareOptimize has helped numerous healthcare organizations succeed for more than a decade. For more information, please call 855.937.8475.

Major Insurer’s Value-Based Primary Care Gamble Is Paying Off
Friday, November 6th, 2020

Humana is reaping the rewards of its decision to gamble on value-based primary care, with the national health insurer receiving well over $600 million in additional income, resulting in a third-quarter profit of $1.3 billion. Humana’s venture into better primary care arrives at a time when healthcare prices are increasing, and insurers are searching for ways to cut costs on medical claims.

When more money is allocated initially for primary care, including screenings and preventative care, research has shown long term cost savings. Humana beneficiaries tend to be seniors in Medicare Advantage programs and cost more than younger, healthier patients, so that investment pays off. Better care with better outcomes has also led to more member retention, a key element in creating value.

Instead of paying physicians for each treatment they offer, which is how health plans historically charged for medical care, Humana pays primary-care practices a fixed monthly fee per patient. This practice is becoming more widespread, especially after the coronavirus outbreak stopped patients from accessing regular care and drained income from medical practices. When people stopped visiting their doctors’ offices, several value-based practices still received payments.

Humana’s Medicare Advantage members receiving treatment from physicians in value-based contracts last year could have spent an additional $4 billion in medical costs if they had continued their care from doctors paid the conventional way, according to the current annual value-based care study from Humana. In contrast with standard Medicare, participants of value-based plans have seen thirty percent fewer hospital stays and ten percent fewer ER visits.

To read more, please visit https://www.businessinsider.com/humana-ceo-lays-out-approach-to-primary-care-clinics-2020-11.

This update is provided by CareOptimize. We provide healthcare management consulting services and products, managed care solutions, value-based expertise, Nextgen EHR utilities, MIPS consulting, and more. CareOptimize has helped numerous healthcare organizations succeed for more than a decade. For more information, please call 855.937.8475.

The Difficulties Involved in Capitated Payment Models
Wednesday, November 4th, 2020

The pandemic and subsequent need to find innovative ways to retain patients while offices remained closed uncovered a basic truth: value based medicine is here to stay. Risk-bearing arrangements can be very successful for providers and allow for more flexibility, but varying state regulations and guidelines make deciding what type of model is good for any particular practice challenging. Under the umbrella of value-based care, reimbursement models take on varying levels of risk for providers and insurers.

Full capitation is an arrangement term when a provider is paid a fixed rate to provide patient or group care. While the rewards for this model can be high, this type of value-based arrangement can be quite complicated and is not advised if a provider has never dipped their toes into value-based care. Capitated models require the ability to track patient data along with an understanding of the cultural changes inherent in the change.

Shared-savings agreements, when providers are compensated for achieving financial and quality benchmarks, are good places for an initial value-based arrangement. Tightly aligned with Medicare, shared savings agreements can also be offered by private insurers. Some bear only upside risk while others contain some downside risk.

Instituting value-based care across the country is challenging because states have a hodgepodge of distinct regulations. Some have loose regulations, while others are quite stringent with their policies. There are some states where providers are treated like insurers, which implies they have to keep a certain amount of financial capital and undergo a burdensome registration process. Semi-annual filings are compulsory in a few circumstances, including fees and disclosing ownership.

The goal is to avoid what transpired in the 1990s from happening again. During this decade, some providers eventually filed for bankruptcy or closed their doors after taking on full-risk contracts, which resulted in insurance companies incurring significant losses. Following these events, legislation was introduced by federal and state governments mandating providers who bear financial risk to keep similar levels of reserves around as the insurance companies.

This update is provided by CareOptimize. We provide healthcare management consulting services and products, managed care solutions, value-based expertise, Nextgen EHR utilities, MIPS consulting, and more. CareOptimize has helped numerous healthcare organizations succeed for more than a decade. For more information, please call 855.937.8475.