Choosing the right value-based care model for your practice

Healthcare practices and organizations are increasingly adopting value-based care (VBC) models, either to participate in CMS programs and private payer contracts, or to focus on improving care quality and keeping costs down for both patients and providers. The landscape of quality-based programs continues to grow, and as a busy physician, you need to assess which models might be most beneficial to you, your practice, and your patients in both the short and long term.

The models discussed here span a continuum of financial risk, from fee-for-service payments linked to quality and value—including pay-for-performance programs such as MIPS—to shared savings and shared risk arrangements and population-based payments such as global capitation.

Choosing the right model is step one. But organizations tend to find that the harder challenge is building the operational infrastructure to perform within it.  

It’s important to note that VBC programs are not limited to government payers: many commercial and private payers also offer or require participation in some quality-based programs. However, government payers currently play a large role in bringing VBC to US healthcare, partly due to the Centers for Medicare & Medicaid mandate to have 100% of traditional Medicare beneficiaries enrolled in accountable value-based care relationships by 2030.¹

Let’s take a closer look at these alternative payment models and what questions you should consider while planning for your move into VBC.

Pay for performance: identifying and engaging patients

Pay for performance (P4P) is the payment model most like the more familiar fee-for-service approach, which reimburses clinicians for each service they provide regardless of health outcomes. P4P gives providers the opportunity to be paid for coordinating care and delivering tools and services to help patients be more active in their own care, like enrolling qualifying patients in a chronic or transitional care management program.

Pay for performance programs are designed to carry no downside risk (e.g., financial penalties) and may be relatively straightforward for practices — particularly those new to value-based care—to implement. Still, there are important considerations to weigh around P4P programs.

Are pay for performance programs right for your practice?

Consider asking yourself these questions when evaluating your organization’s readiness to participate in pay for performance programs, such as Medicare’s Chronic and Transitional Care Management programs:²

Do I have an efficient and accurate medical billing function?

Patient registration, medical coding, claim submission, and all the other elements of fee-for-service medical billing are core competencies you’ll need to manage successful pay for performance programs. Most P4P arrangements pay you for work you do in addition to standard care, so this function is a must-have.

Can I support the work before reimbursement arrives?

Programs such as Medicare’s Chronic Care Management reimburse practices through the Medicare Physician Fee Schedule for qualifying services that have been delivered and documented.^3-4 Before participating, consider whether your practice has the staffing, workflows, documentation processes, and cash-flow capacity to support the work before reimbursement arrives.

Can I identify and manage patients who are eligible for care management programs?

How well can you see your patient population at a glance? You likely know your patients well individually, but your technology should also help you identify relevant groups across the practice. For example, Medicare’s Chronic Care Management program generally requires patients to have two or more chronic conditions. Care management should also be embedded in the patient chart rather than siloed in a separate tool, so clinicians can access care plans within their usual workflows and care managers can work from current clinical data.

Within athenaOne®, Data Explorer helps teams identify relevant patient populations and care gaps, while Chart Assistant with Sage™ surfaces patient-specific insights from the chart to support pre-visit preparation—all within existing workflows.

Can I engage patients with self-service tools and proactive communication?

Part of running a successful P4P program is engaging and informing your patients about your new offering and how it works. Consider using a patient engagement solution with both outreach capabilities and self-service patient tools to remind patients of upcoming appointments, share preventative care actions, and other communications.

Do I serve the right patient populations?

One simple question to ask is, “Do I serve the right patients for this program?” Be sure to determine who qualifies for enrollment in specific programs and if you have enough patients to participate.

athenaOne’s patient engagement capabilities can be especially helpful when participating in P4P programs, enabling you to proactively communicate with your patient population and provide them with self-service tools to improve key quality measures.

athenaOne’s population health tools are also helpful for seeing your patient population at a glance, enabling you to understand which programs you’re best suited for.

The four types of value-based care models — pay for performance (P4P), quality incentives, shared savings and risk, and global capitation — exist on a spectrum of risk and each requires unique proficiencies and expertise.

Quality incentives: tracking quality with CEHRT

Quality incentives is currently the most popular value-based care model, primarily due to the Merit-based Incentive Payment System (MIPS) program, which is compulsory for many practices that are enrolled in Medicare.⁴ Quality incentives like MIPS reward providers who meet certain quality- and performance-based metrics for a defined set of patients.

CMS has proposed sunsetting Traditional MIPS after the 2028 performance year, a change that, if finalized, would shift most eligible clinicians to MIPS Value Pathways beginning in 2029.⁵ As CMS accelerates this transition and the broader move toward digital quality reporting, athenaOne’s federally certified technology helps capture structured data within existing workflows and supports reporting on electronic clinical quality measures (eCQMs), helping practices prepare as requirements evolve.

Quality incentive programs do not involve downside risk in the same way as models that hold providers accountable for both quality and cost. MIPS can nevertheless reduce future Medicare Part B reimbursements: a final score below the performance threshold can result in a negative payment adjustment of up to 9% during the associated payment year.⁶ CMS applies the adjustment claim by claim to covered professional services; it is not collected as a lump-sum repayment.

And, since payments are based on performance over a 12-month period, payment can lag for years after services have been provided and key metrics have been met.

Are quality incentive programs right for your practice?

Let’s take a closer look at considerations for participation in quality incentive programs:

Do I have an efficient and accurate medical billing function?

MIPS operates on top of fee-for-service reimbursement rather than replacing it. Practices continue to bill Medicare Part B for covered professional services through standard medical billing processes, and CMS applies a positive, neutral, or negative MIPS adjustment to the Medicare-paid amount on those claims during the associated payment year. Because the adjustment is based on an earlier performance year, today’s results affect future reimbursement.

Do I prefer upfront or trailing payments and/or reimbursements?

Quality incentive programs like MIPS are measured over the course of a “performance year.” Your performance is then calculated during the subsequent year, and adjustments to Part B take effect the following year. Be aware that you won’t see any incentive payments based on your first-year-performance for over two years.

Do I have a Certified Electronic Health Records Technology (CEHRT) solution?

In an effort to promote interoperability between health systems, the Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) have set criteria for how health data is structured and stored in an electronic health records or electronic medical records systems.⁷ Having an ONC-certified EHR is required for participation in certain programs, like MIPS.

Can I close care and diagnosis gaps at the point of care?

Closing care and diagnosis gaps is an important element of many value-based care programs. The ability to see and address these gaps while you’re with your patient is crucial. athenaOne’s Clinically Inferred Diagnosis Gaps capability uses AI to identify potential diagnosis gaps from comprehensive chart data and surface supporting evidence directly in the clinical workflow for clinician review.

Can I track and report on program-specific quality measures?

To leverage a quality incentive program, you will need to track and report on specific quality measures like controlling blood pressure, various screenings, post-intervention assessments, and many others. This capability is crucial for success under these kinds of metrics.

athenaOne’s ONC-certified EHR product is designed to support organizations participating in MIPS and other quality incentive programs. MIPS dashboards and reporting help you track your performance throughout the year and also identify your strongest 90-day reporting period. In Performance Year 2024, 94.77%* of eligible athenaOne clinicians reporting Traditional MIPS earned a positive payment adjustment, compared with 91.40% nationally.⁸

Shared savings and risk: ACOs and referral networks

Shared savings and risk programs encourage practices—or groups of practices organized into accountable care organizations (ACOs)—to manage costs associated with groups of high-risk patients. Savings are tracked over a period of time and distributed back to participating providers as an incentive payment.

Programs like the Medicare Shared Savings Program (MSSP) build in both upside and downside risk, so it’s important to be confident in your ability to both manage costs and track crucial information for large panels of patients.⁹

Are shared savings and risk programs right for your practice?

Here are a few important considerations for shared savings and risk:

Do I have an efficient and accurate medical billing function?  

Shared savings and risk programs such as the MSSP still rely primarily on fee-for-service reimbursement, so participating practices continue to submit Medicare claims through standard billing processes. Those claims help determine patient attribution and track total cost of care, while quality data is reported separately. After the performance year, CMS compares the ACO’s actual spending with its financial benchmark. The ACO may receive shared savings if it meets applicable cost and quality requirements — or owe shared losses if it participates in a downside-risk model and spending exceeds the benchmark. Accurate, trackable revenue cycle management processes therefore support both current reimbursement and future ACO performance.

Do I prefer upfront or trailing payments and/or reimbursements?

Shared savings and risk programs reward participating ACOs with a portion of the savings they achieve over a period of time for a specific panel of patients (this is known as a performance payment). Performance payments, like quality incentives, are paid out after savings have been calculated for the performance period. Note: if you operate in a rural or underserved area, you may qualify for upfront payments through the MSSP Advance Investment Payments (AIP) program.¹⁰

Am I part of an ACO or am I willing to join an ACO?

Shared savings and risk programs encourage healthcare providers to form ACOs that can share resources, infrastructure, and strategies for improving quality and managing costs. For smaller practices that want to participate in value-based care but may not have the infrastructure to manage financial risk independently, joining an ACO can provide added support and help make participation more accessible.

Do I have a strong referral network and thorough knowledge of specialists and other providers in my region?

Shared savings and risk programs work, in part, but focusing on the total cost of patients’ care, not just the care they receive at your practice. To be successful, it’s beneficial to have a highly interoperable EHR and to be part of a strong referral network in your area.

Can I quickly and accurately segment patients according to their Hierarchical Condition Categories (HCC) and Risk Adjustment Factors (RAF) scores?

Quantifying patients’ risk levels is crucial for managing large panels of patients in shared savings and risk program.¹¹ Does your healthcare IT solution enable you to do this?

athenaOne’s practice and revenue cycle management capabilities enable practices and ACOs to efficiently manage medical billing tasks and maintain trackable records for MIPS reporting. For practices ready to enter value-based care, the athenahealth ACO Marketplace offers pre-built connections to partners — such as Aledade, Vytalize, and On Belay — making it easier to find and join an ACO that fits their goals. Once connected, practices can access performance insights and exchange data through athenaOne workflows without building custom integrations.

For practices joining an ACO, athenaConnect™ provides a single point of connection between the ACO and its athenaOne members, supporting standardized, two-way data exchange within existing workflows and visibility into network performance.

Global capitation: population health and risk adjustments

Like shared savings and risk, global capitation programs incentivize healthcare organizations to carefully manage the costs of care for groups of high-risk patients. Typically, you’ll receive a set amount each month per enrolled patient; if you keep costs below that amount, you get to keep the balance.

Global capitation programs are sometimes called “full risk” because the healthcare provider takes on the entirety of the financial risk built into the program. This risk is counterbalanced by the potential for a greater reward.

Below, you’ll notice that we don’t ask about your medical billing and revenue cycle management capabilities for global capitation programs. Of the four payment models discussed here, global capitation is the only approach that does not require an efficient fee-for-service-style revenue cycle management process.

Are global capitation programs right for your practice?

Here are some factors to consider when evaluating healthcare capitation programs:

Do I prefer upfront or trailing payments and/or reimbursements?

Of the four categories of VBC payment models, global capitation is the only type designed using upfront or capitated payments. Typically, participating healthcare organizations receive funds to pay for patients’ care ahead of time; any surplus money is considered a bonus. Capitation programs may be able to support this kind of predictable cashflow is appealing.

Do I have a robust and capable population health solution?

Global capitation programs typically serve large groups of high-risk patients. If you’d like to enroll in a capitation program, it’s important to have a population health solution capable of  analytics, claims data for each attributed patient, and care management at the population level.

Population Intelligence is fully embedded within athenaOne and designed to integrate value-based care workflows for the right user at the right time to support improved quality, reduced cost, and increased access on a single platform:

• Ingest and normalize data from many different sources — adjudicated claim files, payer eligibility and quality rosters, other EHR feeds, hospital discharges, and more.
• Insert normalized data into athenaOne so that it's available for the right user at the right time — in the patient chart, native care management workflows, and in analytics and reporting tools.
• Support advanced population level analytics and enable enterprise care management — the ability for a large enterprise who has providers on different vendors to be able to do care management on the organizational level all using athenaOne Care Management workflows.

Can I quickly and accurately segment patients according to their Hierarchical Condition Categories (HCC) and Risk Adjustment Factors (RAF) scores?

The ability to calculate patients’ level of risk, or the projected cost of their care, is essential for global capitation programs. Ideally, these calculations can be done quickly, even at the point of care.

Success in global capitation programs hinges on accurate and timely analytics of your patient population. athenaOne’s Population Intelligence enables you to identify your highest risk and highest costs patients and use that information to intervene and enroll them into appropriate care management programs.

Plan for today, prepare for tomorrow

No matter where you are in your value-based care journey, the infrastructure you choose should be able to grow with you. Whether your organization is participating in MIPS, joining an ACO, or preparing for full capitation, it shouldn’t have to rebuild its technology foundation at every stage.

athenaOne supports the full journey through one unified platform, a native ACO Marketplace, and network connectivity that expands as you take on more risk. By building on the workflows your teams already use, you can strengthen value-based care performance today while preparing for more complex models tomorrow.

Ready to take the next step in value-based care? Explore athenaOne, or learn more about the athenahealth Marketplace and athenaConnect.