The Centers for Medicare & Medicaid Services have advanced value based care significantly in the last several years, and in a somewhat expected, yet bold move in October 2021, specifically said that they expect all traditional Medicare beneficiaries to be treated by a provider in a value-based care model by 2030. CMS rarely uses such superlative terms (all traditional Medicare beneficiaries), and the Centers for Medicare & Medicaid Services Innovation Center (CMMI) has five stated strategic objectives to achieve this massive undertaking.

The patients at your practice, your staff, the physicians, vendors and other support partners - these are all critical to your success. But when it comes to self care, the most important person at your practice is … you!

Quality measures are a key aspect of primary care, not just because value-based care requires satisfaction to receive incentive payments, but because they can impact patient wellness. At a base level, it is common sense to evaluate an individual for early signs of diseases that could evolve into a more serious issue such as cancer or heart disease. Unfortunately, not all insurance payors have the same idea of what quality measures should be tracked or even what the target values should be. For example, one payor may say hypertension is defined as having a blood pressure of greater than 130/80 while another may say 140/90. Uncontrolled diabetes may be defined as an A1C greater than 8 for one payor and greater than 9 for another. A lack of consistency in these expectations causes confusion for primary care practices and can result in unmet quality measures.

Primary Care Providers (PCP) are problem solvers trained to learn as much as they can about the entire human body. As soon as the patient begins to describe their concern, the PCP is processing the information and evaluating possible solutions or treatments. It is often difficult to determine how much time is needed for a visit because they are trained to not just look at a single problem, but the whole person. Value-based care and mandatory quality measures (or risk losing money) have made the primary care visit even more complex. If a provider runs late, patients become irritated and upset but expect the provider to give them the amount of time needed for whatever “oh by the ways” they mention even if it wasn’t included in the reason for visit.

The Great Resignation is a term with which we as society are all too familiar, and physician practices are definitely not exempt from the sting of The Great Resignation. Throughout the pandemic, healthcare workers (among others) were heralded as heroes, with many public displays of support and care as we all banded together to get through something none of us have ever seen before. Doctors, nurses, and practice staff were showered with support and kindness, sent letters and cards, and were generally appreciated.

Imagine this.

You’re in a new city for a trip, and have checked in to your hotel for the stay. It’s close to dinner time, and you are ready to go out and eat. What do you do? If you’re like most people, you’ll open up one of many websites or apps, such as Google, Yelp, Facebook, or others, and search for dining options near you. You’ll likely look at which ones are the closest options, then see what type of restaurant strikes you.

Medicare Annual Wellness Visits (AWV) are frequently viewed by primary care providers as a tedious visit in which patients see little value. With consistent access to care issues and a shortage of primary care providers, these visits are easy to push to the side and focus on other visits. The problem is, these visits can impact attribution and they are also a key metric in value-based care plans as well as Accountable Care Organization (ACO) requirements to receive incentive payments. So how can a practice balance the need to maintain attribution and satisfy insurance requirements while still providing crucial hands-on care to patients? The answer may be more simple than hiring more providers or limiting new patients. Nurse-led Annual Wellness Visit programs have been proven to effectively meet the AWV requirements while increasing access to the provider for other visits.

It’s the beginning of a new year, so you’ll be hearing a lot about Medicare risk coding and the importance of risk coding. You’ll most likely hear the same story from many different sources - beginning January 1, those patients with amputations suddenly have limbs grow back and patients with certain conditions no longer have those conditions. You as practice leaders and physicians are told by multiple sources about how important capturing appropriate condition coding for your patients is.

Work smarter not harder is a phrase often heard in many settings, not just healthcare but what does that mean in the primary care world? How can we work smarter not harder when there is so much work to be done?  Change in any form can be difficult and scary, especially when it involves new technology.  Finding the right solution and gaining buy-in from providers and team members can be the most difficult part of this process even if the solution will make their job easier.  The key is to engage the affected team members early on, share the vision, acknowledge the loss of the old way, and give them opportunities to participate in the process.

The Extreme and Uncontrollable Circumstances (EUC) adjustment from CMS, also known as Covid protection, has now expired, which means that the overall star ratings for health plans will not be adjusted to account for Covid. There was an overall decline in year over year star ratings over the last two years, with the national average star rating declining from 4.37 in calendar year 2021 to 4.15 in 2022, a decline of 0.22.

You as a primary care leader are responsible to your practice and yourself for financial performance. As value based care evolves for your Medicare patients, this performance is becoming more directly linked to stars performance. There are value based care programs available from CMS directly, as well as payer-specific value based care incentives that your practice might qualify for. There are also basic, upside-only contracts from both entities and more advanced, risk-bearing contracts as your practice matures and can gain through these more advanced contracts.

Primary care, and the leaders, physicians, clinicians, and support team within those primary care offices, are truly at the heart of making healthcare better. As we close out 2022 and enter 2023, there is no better time to focus on something that’s often overlooked in the business of primary care - you and your intentions.

Call-outs, resignations, and limited staffing resources make it challenging to keep up with the day to day requirements of a primary care practice. While many corporations are transitioning to remote or hybrid work and are increasing compensation to remain competitive, it is difficult to make these changes in a field where in person contact is necessary. Telemedicine is certainly a trend here to stay, but most visits still require an in-person appointment so the provider can listen to the patient’s heart, lungs, and perform tests that cannot be done from home.

It seems everywhere you look now, self-service is present from self-check-outs to ordering and paying using a QR code at a restaurant. Self-service, or the digital front door, became even more prominent with the COVID pandemic to reduce face-to-face interactions and the spread of the virus. Healthcare has had self-service options for patients for some time now through patient portals but these options are continually expanding to allow patients to interact with their healthcare team in the way they prefer. These methods can include self-scheduling, text messages to request an appointment or change an existing appointment, paying bills, completing health assessments before arriving at the office, and checking in for an appointment prior to arrival.

Staffing, access, and burnout are like four-letter words in most healthcare settings these days. There aren’t enough people to perform the tasks needed to keep patients flowing through the system or enough providers entering the industry to keep up with the demand resulting in limited access for patients in need of care.

The Institute of Medicine defines primary care as “the provision of whole-person, integrated, accessible, and equitable health care by interprofessional teams that are accountable for addressing the majority of an individual's health and wellness needs across settings and through sustained relationships with patients, families, and communities”. To align insurance carriers, healthcare providers, and patients’ perception of quality healthcare, the first step is to build relationships among the three entities through more collaborative communication.

Merriam-Webster defines quality as the “degree of excellence”. So how do we define the degree of excellence in healthcare? What does quality healthcare look like? This answer can vary depending upon who is asked the question.

Over the past 40 years, we've seen a large shift in primary care and the United States healthcare system. Unfortunately, the changes have resulted in a very broken system, and we now more than ever see the need to correct the flaws.

It’s time to start thinking about 2023. Join us for an online panel with three healthcare executives to discuss strategies for the coming year and beyond.

The National Committee for Quality Assurance (NCQA) has developed a list of metrics and measures they consider pertinent to the assessment of quality in the delivery of healthcare based on access, availability, effectiveness, and outcomes