Value-based care (VBC) may not seem relevant to most otolaryngology practices today, given that many remain mired in a fee-for-service (FFS) payment model that annually reduces reimbursement for clinical services to levels below the rate of inflation and also reduces the perceived value of the specialist delivering those services.
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November 2024But VBC is coming to otolaryngology offices within the next five years through the Centers for Medicare and Medicaid Services (CMS) initiatives, and otolaryngology needs strategies for responding to how value, outcomes, and cost will be captured and measured, both currently and in the future, said Willard C. Harrill, MD, a clinical advisor for the PACES Center for Value in Healthcare and a member of the Physician Payment Policy Workgroup for the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNSF).
“VBC is an opportunity to regain much of what we lost in FFS, but we will surrender the opportunity to define value and distinction for our specialty within this new payment paradigm if we do not focus on what is coming our way now,” Dr. Harrill said.
In an interview with ENTtoday, Dr. Harrill identified several key steps the profession needs to take to prepare for this watershed event, which is marked by evolving payment and quality metrics. He drew not only on his work with these groups but also on his experience co-founding BridgepointMD, a partnership that provides specialty physician group practices the expertise and data technology needed to navigate alternative payment models (APMs).
Building a Better Infrastructure
One of the most important tasks for otolaryngology is to build a better translational infrastructure and workflow that captures the value the profession delivers within claims-based analysis measures (CBAMs), Dr. Harrill noted. CMS, which processes $2.4 billion a day in Medicare claims, has determined that the only current interoperable solution for “value” transparency on that scale is through CBAMs. But there’s a problem, he said: CBAMs do not sufficiently weigh outcomes-based analysis measures (OBAM) when calculating value. Fortunately, within five years, increased OBAM transparency likely will come from evolving electronic health record (EHR) and health information exchange interoperability standards, he noted.
That process will be hastened by Fast Healthcare Interoperability Resources (FHIR) standards, which were developed in 2012 by a nonprofit group as a better system for exchanging healthcare data between different computer systems, he noted. “FHIR will provide structured data transparency to capture next-generation quality and outcomes measures on an entirely different level in the next five years,” Dr. Harrill said. “That is the future.”
Make no mistake, he added: “If physicians do not lead in the development of condition-specific OBAMs, the payers will, leaving physicians once again on the sidelines in a race to the bottom, as is the case with FFS.”
Dr. Harrill called on the AAO-HNSF, the Triological Society, and other specialty groups “to collaborate in retooling clinical guidelines and quality outcome measures as validated components for OBAM, based on our scope-of-knowledge expertise.” Without such efforts, “this will be done by another third party that does not have our expertise tied to real patient experience.”
Nailing Down Risk-Adjusted Scores
Otolaryngology also needs to work on accurately documenting capturable data within an episode of care and defining the patient’s risk-adjusted factor (RAF) score, which measures predictable spending risk within the management of a clinical condition, Dr. Harrill noted. RAF scores represent the patient’s disease severity, chronic comorbidity, surgical risk, and other critical factors that translate to higher expenditures within the patient’s care journey. Without such information, physician cost variability within episodes of care “can make you look like a ‘bad physician,’ or at the least an overutilizer, which in the eyes of most payers is basically the same thing,” he said.
So, what is the best solution? “The only way to capture disease severity in a structured, interoperable place in your clinical notes is via your clinical assessment and plan coding,” Dr. Harrill said. “That is the source for RAF analysis and episode TCOC [total cost of care] standardization within a claims-based analysis by the payers.”
You have to have the data documentation and analytics infra-structure in place to tell the patient’s acuity story through ICD-10 coding.” — Willard C. Harrill, MD