Any industry that is responsible for nearly 20 percent of the nation’s gross domestic product will take some time to transform towards value-based care. The journey is going to be long and different for each organization. Local markets, regional biases, federal and state regulations, as well as the institutional structure and corporate cultures will all contribute to the uniqueness of every health provider’s situation.

While some organizations need to put their financial houses in order, others have optimized their financial performance to the point where efficiencies are more difficult to draw out. For some, success may require providers to take action that reduces FFS payments with potential to undermine financial stability for the short term. Waiting too long to make necessary investments, however exposes the organization to the same risk.

The next stage in the journey from providing care to managing health is putting a roadmap in place for transitioning from volume to value. Bearing population risk means concentrating on the value of care delivered to a defined population, and it requires innovative and transformational care delivery models to manage different risk segments. Timing for this is everything and will vary in each market.

 

Building a Clinical Foundation for Value-Based Care

The role of the physician advisor (PA) has become essential to healthcare organizations today, especially with the need to build an infrastructure that supports the movement toward Value-Based Care. Keeping up with changes to policies and regulations from CMS and managed care payers require the kind of time and attention that would be difficult for most clinical professionals. Physicians who can assist their peers and other hospital personnel in these matters are more essential than ever today. While this role began about twenty years ago with a focus on Medicare compliance, utilization management and review functions, reversal and management of denials, and billing status determinations, the physician advisor role has in some organizations expanded beyond these functions. To support the move towards value-based care, the roles are expanding to include the support of care progression, the appropriate level of care placement, management of length of stay (LOS) through leading practices, appropriate utilization of clinical resources, clinical documentation improvement, payor contracting, revenue cycle, ongoing physician education, clinical quality improvement and safety/risk management when the opportunity presents itself.

Physician advisors should be involved in all of these areas if the organization is going to accomplish the largest return on investment from this role. A physician advisor’s typical day may consist of attending various multidisciplinary meetings with care management and clinical documentation teams regarding identified concerns, while ensuring compliance, seeing that quality care is being provided, and staff is communicating effectively.