New to VBC? Consider these programs

If you’re just starting out, consider these low-risk, low-barrier value-based care programs

If you're ready to participate in a value-based care (VBC) program for the first time, be sure to pick your quality-based program carefully. There are many programs available to choose from, differing in payer, reimbursement methods, and levels of financial risk and potential reward. Many medical practices starting out with VBC look for a quality program with lower barriers to entry: that is, programs that carry minimal financial risk, lower administrative burdens, and accommodate incremental changes to care delivery.

To help you make this important decision, we've put together a list of common, entry-level programs—from both government and commercial payers—to consider as you start building VBC into your care model. Let’s take a closer look.

Government payer programs: Centers for Medicare & Medicaid Services

The Centers for Medicare & Medicaid Services (CMS) is one of the earliest and most active drivers in the move to value-based care.¹ CMS offers a variety of programs built around Alternative Payment Models (APM), as well as a wealth of support resources to help you understand and be successful in the programs they offer. The selection of CMS programs included below are less complex than other VBC programs; some basically offer quality-oriented incentives on top of more traditional fee-for-service models. In general, these programs are also more established than many emerging programs, so both CMS and the industry have had time to test and optimize how they function.

Here are some of CMS’s quality-based programs to consider if you’re still getting familiar with value-based care.

Merit-Based Incentive Payment System (MIPS)

MIPS, which is part of CMS’s Quality Payment Program (QPP), was established in 2015 with the passage of the Medicare Access and CHIP Reauthorization Act (MACRA).² The program replaced the Meaningful Use provisions of the HITECH Act (2009), which is now wrapped into MIPS as the Promoting Interoperability pillar. This lineage reaching back to 2009 makes MIPS a highly established program among VBC generally. Many medical practices in the US have experience with and learnings from MIPS, even as many are still considering testing the program. This established industry knowledge can be an important benefit to you as you consider enrollment.

MIPS is designed for Medicare Part B clinicians and evaluates providers’ performance in specific measures and earn either a positive or negative payment adjustment based on that performance. Those measures include quality, cost, improvement activities, and promoting interoperability.⁴ Incentives are distributed as fee schedule adjustments to Medicare Part B (either positive or negative), which take effect two years after the performance year closes.

Why choose MIPS?

• MIPS is the most common value-based care program and is a great starting point practices that see Medicare beneficiaries.
• Practices can select from a wide range of quality measures so the program can be tailored to your strengths.
• MIPS presents controlled risk because providers avoid penalties by meeting performance thresholds. Under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the maximum penalty under MIPS is 9%.⁵
• Enrollment in MIPS is currently required for many Medicare Part B beneficiaries and will be mandatory for all Medicare Part B recipients by 2030.⁶

MIPS Value Pathways (MVPs)

MIPS Value Pathways (MVPs) are a new reporting options within MIPS. The model is designed with multiple “pathways” which are each developed around specific specialties and clinical conditions. These pre-built pathways make it easier for specialists like women’s health and orthopedics physicians to participate in MIPS by tailoring the program and offering a simplified reporting process.⁷

Why choose MVPs?

• MVPs deliver the same benefits as MIPS, streamlined with fewer reporting requirements and tailored to fit certain specialties and conditions.
• Participants take on known levels of controlled downside risk.
• CMS also provides more targeted, specialty-specific performance feedback to practices in an MVP which can help those just starting out to be more successful more quickly.

Primary Care First (PCF)

The Primary Care First program provides financial incentives to primary care practices that deliver high-quality care while reducing healthcare costs. Participating practices are paid both a monthly fee and an additional performance-based incentive. The program is well-suited for practices that run, or want to run, a management program for patients with multiple chronic diseases.⁸

Why choose PCF?

• PCF presents less downside risk than many APMs and is tailored to the needs of primary care physicians.
• The combination of a monthly care management fee and periodic performance-based fee provides both revenue stability and financial incentives.
• Can be an easier program to stand up for medical practices that already offer chronic care management services.

Medicare Shared Savings Program (MSSP)

The Medicare Shared Savings Program (MSSP) is designed to encourage healthcare providers to work together to improve the quality of care for Medicare beneficiaries while reducing costs. It allows Accountable Care Organizations (ACOs) to share in the savings they generate for Medicare by meeting specific quality and cost benchmarks. The program aims to enhance patient care coordination and promote preventive services, ultimately leading to better health outcomes for seniors.

MSSP offers two levels of risk though the BASIC and ENHANCED tracks. BASIC levels A and B are entry-level participation options for ACOs with upside-only risk (i.e., no financial penalties).⁹

Why choose MSSP?

• MSSP’s multi-track design enables participating practices to choose the level or risk they take on, including upside-risk-only.
• If you’re considering joining an ACO, MSSP is a great reason to do so.
• MSSP is one of CMS’ longest running and most successful programs, with a proven track record of success.¹⁰

ACO REACH (formerly Global and Professional Direct Contracting Model)

If you are part of an ACO or considering forming one, ACO REACH (Accountable Care Organization Realizing Equity, Access, and Community Health) is for you. The program is designed to enhance healthcare delivery for certain Medicare beneficiaries by promoting health equity and improving access to care. It encourages participating ACOs to take on financial risk while providing coordinated, patient-centered care, with a focus on addressing social determinants of health.

ACO REACH pays a monthly capitated payment (also called per-member-per-month, or PMPM) per Medicare patient. Practices are also eligible to receive a share of the savings the ACO generates for Medicare.¹¹

Why choose ACO REACH?

• Predictable monthly capitated payments offer stability to practices that are new to VBC.
• Forming or joining an ACO distributes risk across the participating practices.
• ACO REACH’s focus on social determinants of health makes it well-suited for medical practices working with underserved communities.

Medicaid Managed Care Plans

Medicaid managed care plans provide Medicaid health benefits and additional services through contracted arrangements between state Medicaid agencies and managed care organizations (MCOs). These plans operate under a capitation payment model, where MCOs receive a set amount per member per month to manage the care of enrolled individuals. Most, but not all, states offer managed care arrangements for Medicaid. Some states require that Medicaid beneficiaries receive care through an MCO.¹²

Due to the quality measures these plans tend to target, healthcare organizations delivering services to address behavioral health, disease management, and perinatal/birth outcomes should consider Medicaid Managed Care Plans.¹³

Why choose Medicaid Managed Care Plans?

• Medicaid Managed Care Plans are the most common way Medicaid recipients receive care.
• Depending on the state and specific care plan, participants receive monthly capitated payments and/or risk-based performance payments.
• If you operate in a state that offers an MCO and you see Medicaid patients, it is likely a good fit for you.

Medicaid Health Homes

Medicaid Health Homes is a care delivery model designed to provide coordinated, comprehensive care for individuals with chronic conditions like heart disease, stroke, high blood pressure, diabetes, and others. Similar to PCMHs, Health Homes integrate physical health, behavioral health, and social services to improve health outcomes and enhance patient engagement for high-need Medicaid beneficiaries. By focusing on a patient-centered approach, Health Homes aim to reduce healthcare costs and improve the quality of care through better management of complex health needs.¹⁴

Why choose Medicaid Health Homes?

• Reimbursements for Medicaid Health Homes are typically paid out through a combination of per-member-per-month (PMPM) payments and performance-based incentives.
• Predictable monthly capitated payments offer stability to practices who are new to VBC.
• If you’re a practice managing patients with chronic conditions, Medicaid Health Homes can provide additional revenue for care coordination and management you’re already doing.

Chronic Care Management (CCM) and Transitional Care Management (TCM)

For participating practices, Medicare will pay for chronic care services delivered to patients who have multiple chronic conditions listed on the Medicare Physician Fee Schedule (PFS). Practices can bill for chronic care coordination or remote monitoring of patients, offering additional revenue streams with low administrative burdens. CCM services include maintaining comprehensive care plans, managing care transitions, continuous communication with a designated care team member, a focus on preventative care, and others.¹⁵

The Transitional Care Management program is similar to CCM but focuses on facilitating and coordinating a patient’s transition from a hospital or in-patient setting to their home.¹⁶ Transitional care services may include assessing ongoing patient needs and risks, arranging follow-up appointments with specialists, providing recommendations and resources on self-management of symptoms, and generally facilitating communication between care providers, the patient, and family members.¹⁷

Participating practices are paid for their participation in these programs by submitting specific billing codes established by CMS. If you’re interested in starting a CCM or TCM program, it’s important to verify that your healthcare IT is compatible with remote monitoring tools.

Why choose CCM and/or TCM?

• Starting a CCM or TCM program at your practice can add a revenue stream for ongoing care provided outside typical face-to-face physician/patient encounters.
• Often a CCM or TCM program can be overseen and administered by a non-physician staff member in a designated care management role.
• The concurrent, code-based billing model presents minimal financial risk.

Commercial payer value-based programs

CMS is not the only administrator of value-based care programs in the US. Increasingly, commercial payers are also offering programs to reduce costs and incentivize medical practices toward certain quality measures. Here are a few types of programs available from commercial payers.

Commercial pay for performance (P4P) programs

Similar to certain programs under CMS, commercial P4P models reward practices for achieving specific quality benchmarks without requiring practices to take on financial risk. Examples include performance-based contracts offered by insurers like Blue Cross Blue Shield¹⁸ or UnitedHealthcare.¹⁹

Having your payer data integrated directly into your EHR is a useful technology capability if you’re interested in commercial VBC programs so you can monitor and track the different payer programs you participate in. For example, athenaOne users can view patients’ insurance information, including real-time eligibility checks, directly within the EHR workflow during patient encounters.

Why choose commercial P4P?

• If you operate in an area where a high percentage of people use a particular insurance provider, you will likely want to enroll in any relevant P4P programs offered by that insurer so you’re eligible to participate.
• Specific programs and program requirements can be selected according to your practices’ strengths and competencies.
• Enables practices to test quality-based requirements without financial risk.

Patient-Centered Medical Home (PCMH)

Patient-Centered Medical Home (PCMH) programs offered by private insurers (rather than through NCQA) encourage care coordination, delivering comprehensive services like preventive care and chronic disease management, and behavioral health integration for high-need, high-cost patients. Practices are incentivized to actively engage patients in their care through shared decision-making and personalized care plans, as well as utilizing technology like an EHR to enhance communication. Quality measurement and continuous improvement are central to these programs. Payments typically take the form of shared savings or adjusted reimbursement rates.²⁰

Why choose PCMH?

• PCMH programs may reward you for the high-quality care you’re already delivering to patients.
• Most are low-risk or upside-only models that achieve VBC’s top goals of improving care while reducing costs.

Tips for Entry-Level Participation

If you feel overwhelmed by the variety of programs, models, and payment methods that fit beneath the umbrella of value-based care, you’re not alone. Thankfully, you can take this journey step-by-step. Here are a few tips for success we’ve learned by helping medical practices of all kinds get their footing with value-based care and strengthen their financial health.

Start small

If possible, begin with upside-only risk models or fee enhancements for quality care. For example, the BASIC track under MSSP is a great option because it does not expose participants to downside risk. MSSP also encourages the formation of ACOs which further help to mitigate risk or distribute it among a larger group of healthcare entities.

Leverage support

As US healthcare continues to shift toward value-based care models, helpful resources are growing up to support healthcare providers striving to understand and be successful in the programs they choose.

For example, be sure to leverage technical assistance from organizations like Quality Improvement Networks (QIN-QIOs).

Your healthcare IT partner should also support you in evaluating and participating in VBC. athenaOne users have dedicated Customer Success Managers they can work with to find important information on program specifics, understand and comply with reporting guidelines and best practices, and to receive support for getting the most out of the athenaOne platform as they research and test different programs. Our technology, regulatory, and healthcare operations experts have a wealth of knowledge and experience to share.

Invest in data tools

How much visibility do you have into your data? Can you analyze and report on patient health data, population health data, revenue management data, etc.? If your answer is, “no” or “I don’t know,” you may want to consider investing in healthcare IT with these capabilities. Even basic analytics can help track performance and simplify reporting for certain programs.

For instance, our integrated athenaOne platform gives you easy access to an Insights Dashboard for tracking a variety of metrics, population health analytics, and a variety of health and financial data reporting. These capabilities all support success in various VBC programs.

athenaOne for value-based care success

The programs we’ve outlined allow medical practices to dip their toes into value-based care without taking on significant financial or operational risks upfront. Another important way to mitigate these risks is to partner with a technology and services provider like athenaOne.

athenaOne is an all-in-one platform for electronic health records, medical billing and practice management, and patient engagement. Our ever-growing platform is built with the capabilities you’ll need most to be successful with value-based care.

Our commitment to our customers success is having an impact: for example, athenaOne users outperform national averages across nearly all MIPS metric, including above-average performance in both Quality and Promoting Interoperability scores.

If you’d like to learn more about value-based care and how it might benefit you and your patients, read our collection of VBC resources or browse the articles below.

Many medical practices starting out with VBC look for a quality program with lower barriers to entry: that is, programs that carry minimal financial risk, lower administrative burdens, and accommodate incremental changes to care delivery.