Move to value-based reimbursement taxes EHRs

As the federal government and private insurers switch from fee-for-service reimbursements to payments based on patient outcomes, primary care physicians must shift how they bill payers.

That shift, however, won’t be easy, according to health information technology experts. That’s because most electronic health records (EHR) system implementations do not facilitate this new way of paying for patent care.

“EHRs would work perfectly well to handle this [reimbursement model] if all the care was provided in one place. But you can’t measure outcomes if the treatment is everywhere – at rehabilitation facilities, primary care physicians [and] at hospitals,” said Steven D. Weinman, MBA, principal at healthcare consulting firm FQHC Associates based in Gainesville, Florida.

Some primary care physicians have an advantage when it comes to gathering the data required under value-based reimbursement (VBR).

Those are the primary care physicians who are tied into bigger healthcare systems and either operate on the same EHR or have a high level of interoperability among systems used by other clinicians within the healthcare ecosystem, Weinman said.

But those physicians as well as those in independent private practices need to ask: How can they get all the patient data needed for VBR?

Most physicians are going to face significant challenges on this front, said Pamela Ballou-Nelson, RN, MSPH, PhD, PCMH CCE, a senior consultant with the Medical Group Management Association Healthcare Consulting Group.

Ballou-Nelson pointed to one client as case in point. The client, a primary care physician who has a high volume of Medicare patients, could soon move into Medicare’s Quality Payment Program that focuses on outcome-based payment.. But the physician’s patients also receive a significant amount of care at the regional hospital, yet due to a lack of interoperability between the physician and the hospital, the physician can’t electronically access the hospital data required for VBR.

It’s a typical scenario, she said.

“The biggest cry I hear from [physicians] is that we can’t get the data from our systems,” Ballou-Nelson said, explaining that physicians will need EHRs that can track a range of data points – from quality and outcomes to costs and coding.

“There’s going to be a need to step up the capabilities of the EHR as we move into the value-based model. We’re going to have to have more data from EHRs and the ability to aggregate data, and we’re going to have to have more interoperability,” she added.

Next: Preparing for the new payment system

Like Weinman, Ballou-Nelson said primary care physicians who are already tied into larger healthcare systems have an advantage here. But both Ballou-Nelson and Weinman said all physicians can start to take some steps to better prepare themselves for this evolving payment mechanism. Those steps include:

• Working with EHR vendors to create and/or implement the data capabilities required to bill under value-based reimbursement;

• Selecting and implementing the same EHRs as other providers and healthcare organizations within their community to ensure that data can be shared until true interoperability is achieved – a move that Ballou-Nelson acknowledged is a significant investment of resources and one that will require doctors to consider both short-term requirements and long-term goals; and

• Joining with other physician practices and healthcare organizations to create an ecosystem where data can be shared among those clinicians most likely to treat the same groups of patients. Ballou-Nelson said that’s currently happening in the form of accountable care organizations (ACOs), clinically integrated networks (CINs) and independent physician associations (IPAs).

Weinman said primary care physicians must prepare their EHRs to operate successfully under value-based reimbursement, which he said is inevitable and indeed might even be accelerated with growing pressure to curb healthcare costs and increase efficiencies.

“I’d have to say in five years we’re going to be pretty far down that road,” he said, “and in 10 years we won’t have anything else.”