Close the Gap in Your Value-Based Care Strategy

Thank you everybody for joining us today.

It's very brief webinar, but hopefully in this time, you'll get to hear about value based care strategy and how important it is to make sure that we've got the knowledge, skills, and abilities we need to support these very important programs.

So here's me. This is a couple hairstyles ago, obviously. But, when it I'm I'm here today. Of course, I sit on the AAPC's national advisory board. And when I am not involved in AAPC, my day job is the senior director of policy and regulatory affairs at Centauri Health Solutions. So I'm very happy to be here today, with Stephanie, and she's got a poll for you before we kick things off.

Right. I'm gonna go ahead and launch that poll.

And while you're answering that, I'm just gonna share some housekeeping things. Just a reminder that today's webinar is not approved for CEUs.

And if you have any questions, go ahead and drop that for Dawn in the q and a module. That way, we can stay organized and just have, like, our fun chat in the chat module. But for any questions that you want her to answer at the end, go ahead and drop those in the q and a one.

And then we will be sending out a recording of this along with the slides in your inbox in the next few days.

Alright. So let's go back to the poll. We wanna know, are you currently working with value based care contracts? It looks like most of you are, or you're getting ready to. So that's perfect because that's what we're gonna be talking about today.

And then we wanna know what your biggest challenges are right now. So we're I'm seeing a tie right now between aligning teams across clinical coding and operational workflows as well as ensuring documentation and coding fully support performance.

So I'm gonna go ahead and end the poll right there, and then we can share those results so you can see that too, Don.

Oh, very good. Yes. Luckily, we've got you know, it looks like the majority of folks are working with these contracts and not surprising given that a lot of a lot of you may or may not know that CMS' priority is at least for fee for service Medicare to get folks into value based contracts. So not surprising that a lot of you are there nor that we've got, you know, a good challenges alignment because there are so many different teams that have to be involved when you're executing value based care.

You don't think about even things like IT. You know, you need IT support. You need quality. You need risk.

You know, there's so many different entities. So it's not surprising either that alignment is a distinct challenge.

So excellent.

Thank you all for participating in that. And so we will go ahead and get started with our overview. We're going to discuss the magnitude of the shift to value based care, understand the operational impact on health care organizations and the workforce capabilities needed for success, reviewing examples of what a high performing organization is doing to be successful in value based care, appreciating how leadership in the new CBBA credential, which is from the APC, can elevate performance.

And so with all of that, we're talking about capability building. And so organizations outperform when they build internal expertise across disciplines. And we saw that in our poll where people are concerned about alignment. And this, of course, includes clinical teams and administrators, and that's like coding, CDI, technology and analytics, compliance, payers, community partners. Many are involved in this. So the system we need to align these so the system can execute consistently and not just, you know, kind of scrambling after the fact of being reactive. We're gonna walk through the magnitude, as I said, operational impacts, capability gaps, and how our emerging CBBA role can help elevate performance for organizations that are in this space.

Okay.

So what I have here is a number of headlines that you see popping up here about value based care just to show kind of the magnitude and the different organizations such as CMS, different payers, you know, how different organizations have committed to delivering value based care. So, and these are recent. You can see this one's, you know, February, you know, headline. So very top of the mind for the industry for a variety of organizations, whether they're technology organizations, whether they're government organizations, community organizations, or payers. Everyone has an interest in this topic.

Alright. So I wanted to start out with just a a reminder of the definition of value based care as a model that rewards quality, effectiveness, and coordination of care rather than the number of services delivered. And so we all are familiar with the old fee for service historical service model, which does not reward it it rewards volume and not value.

And to successfully navigate this shift to value based care requires a wide variety of capabilities and expertise, as we've mentioned, that goes beyond our traditional coding roles. And the leadership of these programs, because I know I have some leaders out there, folks that aspire to be leaders, must set a clear vision, a strategic road map, and build a culture of accountability, collaboration, and continuous improvement aligned, and there's that word again, alignment, across clinical, operational, and financial domains.

So no small task to be able to coordinate all of this, but it is possible. So hopefully, you'll come away with some nuggets of knowledge today on how that might be done.

Now value based care, of course, is built on financial risk frameworks. We talk about upside risk as an entry point and downside risk as accountability increases. Now that's why capability matters. The more risk that organizations are taking on, the more you need reliable workflows, analytics, and documentation integrity.

CMS also, as I mentioned, has the goal of transitioning Medicare fee for service beneficiaries into VBC arrangements by twenty thirty. So this is another reason why knowing about this shift and and the orchestration of the alignment needed is not optional.

So operational impact here isn't theoretical. Attribution, and a lot of you may, have seen that word before because we see it, of course, in the risk adjustment space. Attribution determines the population you're measured on, meaning who are you taking care of? You know? Who are you accountable for?

And dashboards and analytics provide visibility into whether you can manage that population proactively. And like I said, not just reactively after the fact, after outcomes have happened, and then you're scrambling.

That's better to do it proactively, and there are analytics that can help you do that.

Documentation completeness is directly linked to accurate risk adjustment and fair payment. Missed diagnoses can lower risk scores and reduce per member per month payments under capitation, which affects financial stability. Because remember, risk adjustment is a component of value based care. So coding leaders aren't just downstream anymore.

You're part of the feedback loop that protects accuracy and enables performance. So if you are doing risk adjustment coding work, you're a very important part of this equation. Right? So, also, those of you in leadership, you know, will understand, you know, why important to, use the tools and resources you have available, you know, to make the most of that upstream role.

So the biggest struggle when organizations try to use fee for service workflows because the natural question is, you know, can't we just, you know, adopt what we're already doing for fee for service? You know, wouldn't that be you know, we don't wanna reinvent the wheel.

But we can't really do that here because it isn't necessarily about hiring smarter people, working harder. It's about whether the roles are designed for this different operating model, and they really aren't. So you can't just adopt the fee for service workflows and then just, you know, put them over to value based care workflows.

So I always say, you know, is my you know, if you try to do that, it's my mother used to say to me and probably, you know, you've heard this. If you do what you've always done, you'll get what you've always gotten. So you need to have new workflows to basically support what you're trying to do in value based care. So but when you do this, you know, using these wrong workflows, many organizations are optimizing the wrong engine.

And, of course, there are struggles here. And I like to use this visual of an iceberg to illustrate that the year end scrambling that results from the cost that you see here is a symptom of of what what ails the process and not the disease itself. Now when organizations say, oh, we're struggling with value based care, they usually point to the visible work that we see. These struggles up here, like a retrospective mindset, siloed ownership, and performance being treated as documentation completion and not going beyond that.

So that's kind of the what we see visibly. But performance is actually driven below the waterline, sort of like the iceberg, you know, the the big ugly part is underneath the water.

So when the operating model isn't built for closed loop execution, you don't just use lose dollars, you use lose trust and time. And, of course, we see here the cost, missed dollars. There are penalties associated with missing certain deadlines and not having certain data in place. You can't forecast in a stable manner, and you have many year end performance surprises, which don't make, you know, financial folks like your CFO very happy. And you can't really get an accurate picture of what's really going on with your membership.

There's burnout from rework and late pivoting because no one likes that you that scrambling that happens reactively. And, of course, it goes without saying provider abrasion. We're asking them too many times for charts. Maybe you're hitting them up once for risk, another time for quality. Here's another time for something else, and that creates a lot of abrasion. But if you've got good alignment, you won't have that struggle and the right mindset. So that's that's kind of what we mean, you know, the the the risks that are if you try to just say, oh, we're just gonna use our fee for service workflows, that will not work, and you will have, some of these costs associated with costs and struggles.

That's our big iceberg. Okay.

So now that we've seen what some of the struggles look like, let's pivot real briefly to what some of the high performers do. Now high performers in this space build and operationalize what you see here on the screen in bold. We have cross functional workflows, and these are, you know, clinical plus coding and CDI and administration and data, inclusive IT, and compliance. So all of these workflows contribute to the overall operational and financial strategy of value based care. And, of course, aligning those is a challenge as we've all identified.

Documentation integrity is a is key in high performance organizations, and that is, of course, making sure that we're following meet criteria, coding to the highest specificity, attending to our problem list hygiene, all of these things that support risk and performance and efficiency.

You know, all the things sometimes that we take for granted.

Also, informatics and analytics as well as decision support tools that flag and support interventions. And this is where you most organizations have teams of people that develop these. So if you're wondering, gosh, who does that in my organization? You likely have an you know, informatics teams that do that and clinicians and are a part of that, and you may even be part of that. Also, you have to have leadership cadence and accountability for continuous improvement. Leadership has an investment in this, and they need to have the right tools and and analytics to be able to tell them, are these programs working?

And we also we can't forget about social determinants of health and community resource integration. Many of you out there know that I'm very much an SDOH warrior, and I speak a lot about it because it's very important for whole person outcomes and equity and is part of the goals of value based care because very much the unique SDOH of communities affects the performance of the organization. So it's called out specifically here. And also goes without saying, we have to care about compliance with everything that we do.

We have to make sure we have internal audits, corrective actions, training programs, all of the things that make sure that we are doing things in a compliant manner. Most of you are probably saying, yes. You know, we're already doing that as part of risk and quality, and that's great. That's a good good place to start.

But you need to make sure that it's being looked at, you know, specifically for your value based care organizations as well.

So what I thought would be interesting for this would be to provide a couple of examples of organizations that are successfully executing value based care. And these are ones that have been in the news. I specifically picked ones that have been in the news and that have talked about, you know, how they are executing. And so I've I've kind of made a little chart that talks about, you know, what they did, you know, and then why it works.

And if you wanted to know more or how to, you know, copy it, you know, what you what you could look at. So in Geisinger's case, they, you can see over here on the left hand side, there were six primary things they did. Of course, there are many other things, but the things that worked the best, I listed over here. And the first is having, you know, standardized care and aligned incentives.

And they what they did was they used bundled payment and a ninety day warranty type situation to manage the full episode of care and reduce complications.

And why it works is it creates reliability at scale and less variation in a care pathway.

The second thing they did where they've got, they they and they scaled with the infrastructure. So that's, you know, what we mean mean by, you know, reliability at scale. They also, hardwired their protocols into electronic workflows. This makes outcomes repeatable and prevents just these, like, scrambles and heroic situations.

So protocols were hardwired into their work workflows in their electronic systems.

They also scaled their VBC participation, and they report about eighty percent of their patients are in, value based care, and this was as of twenty twenty three. And this was generating about greater about forty five million or greater in annual incentives, and that's, of course, just an internal estimate.

And the reason they were able to achieve these outcomes is because they treated value based care as a long term operating strategy and not just a one time project. So, again, this this goes back to scalability, you know, which promotes a longer term operating strategy and not just a one time project. And what they also did, this enabled them to mature into greater risk over time. So they they progressed in their ACO participation towards more advanced risk tracks over time. And so, again, looking at it as a long term operating strategy and not just immediately taking on all the risk or taking none at all. It was a progression.

Another thing that they did, and a lot of you may even be thinking, you know, we we talk about AI a lot in our industry.

And so they did use technology to help them with closed loop, what we call closed loop technology in Teams. So and what they did was they used predictive analytics to support targeted interventions. And so what they they focused on certain populations. And as an example, they focused on, avoidable ED visits and admissions and chronic disease populations.

And so when they did this, they were able to see about a ten percent reduction in avoidable ED visits and admissions for these populations with chronic disease. And one example of of something else they did was they used AI to flag lung nodules with zero missed malignancies reported among their enrolled patients. So they're doing some really innovative things with, AI and NLP. So that's Geisinger.

And, of course, they've done a lot of other things, but I just wanted to point out some of the things that make them a little unique and that have made them successful enough that the the, media and other other organizations wow. They're doing something right. And take a look at this.

Another organization that we have seen doing really great things in value based care is Intermountain Health.

And those of you who are at HealthCon, you know, we we had a speaker from Intermountain Health who was able to tell about, of course, some of the things that they're doing operationally.

So what this organization did was, you know, a little bit different than Geisinger. Although I will say, you know, again, using using data to their advantage, you know, to have long term strategies, not treating this as a one time project, you know, all kind of those same things. But what they did was they built something called Castel, which operationalized value based care at scale.

And what that is is a dedicated population health and analytics capability that allowed them to move beyond their fee for service workflows. So they built a tool, you know, to help them figure out how to operationalize it given their unique population.

They also used an end to end data platform for their risk contracts. And what it did was ingested data, normalized it, and then delivered it into the workflows that support large scale risk populations.

And they reported, just in case anybody's wondering, around eight hundred thousand lives that work under risk. So not a small population by any means. They also, had an emphasis on, you know, the right data at the right time, and it has to be usable. You know, all of the data in the world doesn't mean anything if it can't be accessed and it can't be used. And so they have an emphasis on timely, actionable information for decision making, not just static reporting for one point in time.

They also utilized a proactive outreach model. So they used risk stratification and dedicated care coordination teams to, more proactively outreach to at risk members. And so they look at this and the way this was has been reported as it's a team sport of analytics and coordinators and providers. You know, everybody's on board and has a role in this team approach, and they've gotten some good results from that.

Now their documented outcomes, at least what's been reported is and they're involved with the ACO REACH, which again came from the CMMI, the Centers for Medicare and Medicaid Innovation, as one of the test models.

Those results indicated about eighty six point seven million dollars in savings in twenty this was in twenty twenty three and, extremely high quality scores for the for their second consecutive year. And they attribute this to proactive care coordination and outreach. So to summarize and compare these two examples of high performing BBC programs, Geisinger particularly shows what happens when reliability and are engineered together. Intermountain shows what happens when data and workflows are designed to support proactive execution at scale.

So to some so just to kinda give you how it works a little differently for each organization, you know, depending upon the populations that they're supporting. But we see one theme that keeps popping up. Performance isn't accidental, and it's not the the product of reactive workflows and strategies. It's the result of deliberate capability building across contracts, across data, across workflows, and across governance. So when we talk about alignment, these are two organizations that are doing it well.

So that's why I included these two particular organizations as we talk about this.

So now we talk about, are you ready? You know, even if you're you're not working in value based care, you know, are are you ready? And so we talked about how value based care is an operating model and organizations that build their internal expertise early, you know, across contracting, analytics, workflow management, documentation will outperform those who treat this only as a coding exercise.

Coding excellence remains essential. Of course, that that goes without saying. But the winners in value based care are going to connect it to closed loop execution and measured outcomes. And that capability incidentally is what the CBBA skill set is designed to build.

And so this, of course, is the, certified value based administrator credential that the AAPC offers, and it's new. And so it is designed to help guide that shift from fee for service to value based care via that strategic oversight and cross team alignment. So it will actually show you how to orchestrate that alignment. So up to this point, we've talked about the shift, you know, the operational realities, the workforce gap, and what high performers really do.

And, we see kind of a consistent theme. Value based care isn't something you kind of bolt on to coding operations or or or anything like that. It's a model. And organizations that invest early in that internal expertise, such as understanding contracts, attribution, data signals, workflows are going to perform better because they have that more, you know, proactive mindset that scales, and there's less scrambling, less reactiveness.

Coding excellence still matters, but to high performance, we have to connect that to action, validation, and measurable outcomes. And that connective cap capability is exactly what roles like the CBBA are meant to provide. And, before I entertain some questions and turn it back over to Stephanie, I just wanted to mention that in June, June twenty third and twenty fourth, we have, another conference coming up, and it's RiskCon. I know we're all coming down.

We've just been at HealthCon. RiskCon is coming up, and it's a virtual conference. And because, value based care has such a significant risk adjustment component, in fact, it's viewed as, a credential that risk adjustment professionals might want to consider getting, especially if they're moving into value based care. We're going to be you you will hear value based care discussed quite a bit at this conference.

And so I know in the three sessions that I'm giving, I I talk about it quite a bit. So it's a good conference to attend if you want to continue the conversation with us about how this role promotes alignment, promotes operational and financial stability, especially, if you are working in that space. And so with that, I will take some questions, comments, anything that's on your mind regarding this role and what it does.

Thank you so much, Dawn. That was awesome.

What Luz or Liz did ask a question about the requirements for the CVBA.

And our requirements right now are that you are currently employed a bio risk adjustment auditor, a compliance professional, or an quality improvement specialist or data analyst, and that you're actively working within the value based care space, and that you just have knowledge of value based care models and, how to make those data driven decisions, and are currently collaborating with payers and providers. Dawn, would you say there's anything else that would be recommended for anyone that's looking at taking the CVVA?

So just to kinda describe the curriculum because somebody I know, contributed to it, myself. There, the way that it's structured is that it starts out with an introduction basically of all the roles that are involved because it's it's not just, you know, coding professionals, CDI, auditing. It's, you know, what type of leadership is required, what to kinda give an overview of all the different roles that are involved in executing value based care. Then it talks, of course, about risk adjustment. So it is a review for anybody who is in risk adjustment of of how HCCs work, for example, and, you know, all all of those concepts. And then it also talks about the quality aspect because there are, like I said, upside, downside risk, how all of that works. So we it shifts into that aspect.

And then, there is a section also that talks about tools and technologies that help support analytics and other dashboards, analytics, things that those tools that you need to be able to proactively manage a value based care program. And then the very last part of it is it is like a practical exercise that takes you through the execution. It's a like a a hypothetical organization that wants to do value based care. They've gotta get started.

They've gotta scale. They've gotta measure. They've gotta do they've gotta operationalize everything. And so it takes you through that exercise so that when when you're ready and you take your exam and you pass, because you will pass you will pass, you can just jump right in and have a blueprint that will help you as you are getting ready to do this for an organization.

That's great.

Dawn is also asking, and I'm wondering if we can make this more general. She wants to know how you can start transitioning to value based care for diagnostic imaging. But I wonder if you can just speak to how, organizations can be making that shift from fee for service to value based care.

So that conversation, to make the shift usually starts kind of at the highest levels of the organization. So we're talking folks that are involved in finance. So, typically, your chief financial officers, will be involved, your chief medical officers, because they have to kinda give the ultimate buy in to value based care because it's not insignificant. Because as as we you have seen, CMS, has oversight over this.

So it's not a decision, in other words, that, you know, coders can make or even just, you know, coding leadership. It comes kind of from the top where they decide we're going to do this. Right? And then once that decision is made, you know, they're gonna convene all the appropriate people across the enterprise that would make it happen.

So that would be your clinical informatics folks. It would be folks from provider engagement and provider relations. It would be, you know, medical coding and billing, you know, and all, you know, roles across the the leadership across the revenue cycle. So this is not just coding.

It's also billing. It's documentation. It's auditing. Compliance has to be involved because there are some very specific compliance aspects to this that have to be attended to.

So so it's kind of a top down approach where they decide we are going to be involved in this and they because they have to decide on, are we doing upside risk, downside risk? You know, what are we exactly are we doing? There's a lot of those types of logistical decisions. And then they involve people across the enterprise like we talked about to actually start making the plans to make that happen.

So and then, of course, every everybody reporting to those folks has a role to play in terms of, you know, coding accuracy, clinical documentation improvement, the tools that our our providers are using in their EHRs and their EMRs in terms of workflows that IT might have to deal with. So it's it's quite an undertaking to implement this, and it it it's not something that is, takes a short time to do. It takes a longer longer time to do. But to answer the question, which I hope I did, it kinda comes from the top down where the leadership decides that they're going to enter into these contracts, and then they they make that happen by involving all the people cross enterprise that have a role in it.

Thank you. Yeah. It sounds like there's a lot of big conversations that would have to happen.

And I think, what you shared today would be a great starting point for anyone that is looking to start having those conversations and using some of the, stats that you shared as kind of a backup of why they would be needing to make that shift.

Yes. And then it's possible to be successful. You know, these are two very large, very visible in our industry organization. These are two organizations you see a lot, and they're they're having success.

So it's always good. You know? Again, my mother and others throughout my life have said, you know, surround yourself with people who know more than you do. Right?

And and and you'll you'll never go wrong if you do that, especially here to look to what organ other organizations are doing, what you can take from that to bring to your organization. It's not gonna be exactly the same, but it's a good place to start. Yes.

Donna, I'm wondering if you can see the question that was just dropped into the chat.

Sally and April are both just kinda wondering about their current credentials and if that would qualify them for the exam. I I feel like it it would be fine. I don't think we have really anything that's gating you from taking the CVB Right. CVBA. It's just more of, like, what we would recommend before you get started.

So I I don't know what an MCO is or an IPA.

It looks like, probably a managed care organization.

Okay.

Yep. Also a certified coder. Yes. I would and I agree with you, Stephanie. I think both would be eligible, you know, to study and sit for the exam.

Yes. Okay.

Yes. Managed care. Okay. Great.

And then just one more question.

You talked about closed loop workflows. How does that practically look whenever we're dealing with our coding teams, our clinical teams, analytics, and care management?

So when we say closed loop, it's did something happen that was supposed to happen. Right?

So in in coding, it could be when, the the EMR pops up that someone that there are care gaps with a certain, you know, population or anybody really in the population, care gaps might pop up whether it's risk quality or both. And closing that loop, make sure is is another way of saying, did the provider, you know, address those conditions in an episode of care?

You know, and how did that happen? So that's one way you can look at closing the loop in terms of risk and quality, making sure that identified gaps are closed. Or when risk stratification happens, here's another example of a closed loop, A care manager becomes aware that there's a cohort of patients, that has multiple social determinants of health and several chronic illnesses. And so they're a priority for specific interventions to promote their health or their health and wellness.

And so the closed loop is, did those happen? So did the care manager go out and work with these patients in whatever way specified? And then how do we know it was closed? Because, you know, the care manager, you know, reports that, they didn't visit the maybe they didn't visit the ER as much.

They weren't admitted to the hospital. You know, there's any number of outcomes that could happen, but that's kind of what we mean by closing the loop is did the intervention happen? And then did how did that, you know, impact what we're looking at in terms of outcomes like our ED visits, our readmissions, you know, whatever it is that we're looking at. Another one that I use frequently is related to social determinants.

When there is a referral made to a community organization for for patients that have these determinants, did they get that care, or did they avail themselves of that resource? And did that information come back saying, yes. Check. They did get it.

Again, so that can be tied to outcomes and costs.

Thank you.

Okay. Well, that is the end of our questions, and this and we're actually at the top of our hour. I just saw one come drop in.

Okay. It looks like some other people are just asking more about qualifications around the CVBA. And, actually, there's a question at the end of this. So if you would like to learn more about the CVBA, we're happy to connect you with one of our AAPC experts, and they can kinda dive more into what those qualifications are, and ensure that you're a good candidate for that exam. As well as if you are interested in getting your team certified with a certified risk adjustment coder certification. We see a lot of success in that and just, helping strengthen your risk adjust risk adjustment arm.

And then we also you know, we Don is also one of our webinar speakers frequently, that are CEU approved, and we are happy to get you and your team set up with a subscription on for those. So you'll see two questions following this, whenever we close out here. So just let us know if you're interested in getting connected with an AAPC expert, and we're happy to help you, in the next few days.

With that, I'm gonna go also yes.

Anyone also knows they can you're absolutely welcome to reach out to me. I pride myself on being a very accessible expert. So reach out to me on you know, I'm on LinkedIn, you know, through the AAPC.

I'm here, you know, I'm here to help, and I'm very passionate about supporting my colleagues in the industry.

Thank you so much, Dawn, and thank you everyone for attending today's webinar. I'm gonna go ahead and conclude it. Thank you.

Thank you. Bye.