Creating a Structure to Support Value-Based Contracts

To provide value-based care, providers need to address their process, their technology, and their people. But stakeholder priorities don’t always align. Knowing where and how to start can be the difference between a successful implementation and one that falls short.  

Tune into the latest episode of Value-Based Care Insights featuring host Daniel J. Marino as he welcomes Sarah Hartley and Dr. Purvi Shah, whose expertise in ambulatory clinical documentation improvement (CDI) will help illustrate the need to improve clinical workflows.  In addition, they discuss the risks, challenges and obstacles providers need to navigate in order to better deliver meaningful patient outcomes. 

KEY TAKEAWAYS: 

• Coding and clinical guidelines don’t always align with documentation guidelines 
• To start a CDI program, peer-to-peer education is a critical key to success 
• Providers need to advance clinical workflow and documentation in order to meet the needs of patient populations 

LISTEN TO THE EPISODE:

 

 Transcript:

Daniel J. Marino: 

Welcome to value-based care insights. I'm your host, Daniel Marino. As we have talked about on the program many, many times. There is such a transition that has to occur as we enter into value-based contracts. And in particularly as we enter into risk-based contracts.  

You know, as we all know, value base really allows us to manage the population. We are focused on many different outcomes, many different changes that support our physicians, and whether it be their clinical workflow or changes in the care model. All of that becomes important, especially if we want to take care of patients beyond just the care that is being done within their clinics. The documentation, the care model, the support that we give to our patients, critically important, that drives the success of our value-based contracts.  

But when we think about that, there has been so much attention that it's been given to changes in the care model and the level of outcomes that we need to focus on. Only now are we starting to see the importance of modifications of enhancements to our clinical documentation. So in today's episode, we are going to spend some time talking about the new initiative. And it is not really new, because it has been happening for quite a while, particularly on the hospital side. But the need to really advance the ambulatory clinical documentation improvement. I am excited about today's discussion. 

We've got 2 ladies joining us that have done a great job within their health systems within their programs on building a real strong clinical documentation improvement program on the ambulatory side. First joining us today is Dr. Purvi Shah. 

 Dr. Shah is a primary care intern as a medical director of population health for a large health system here in Chicago, also joined by her colleague, the administrator System director, ambulatory risk adjustment and clinical documentation in Tyler, gritty, Sarah Hartley. 

Sarah and Dr. Shah. Welcome to the program. 

Sarah Hartley:

Thank you. Glad to be here.

Daniel J. Marino:

So Sarah, let us start with you. You know, as I mentioned, and we have done quite a bit of work helping organizations move into value-based care everything from strategies to the managed care contracting, lot of folks have focused on their clinical programs, looking at the outcomes, maybe enhancing some of their systems. Let us focus on the documentation. 

Why, all of a sudden, in your opinion, has this been a focus? Why has it not been a focus sooner as organization started to get involved in value-based care.

Sarah Hartley:

So value-based care has been around for a while. But it has been focused on the hospital side, right? And so as we see the industry shift and wanting to treat our patients on the outpatient basis, keeping them out of the hospital, keeping our costs lower. We are shifting that model to our ambulatory setting and the goal is to keep the patients out of the hospital, and we do that for quality care. Our medical records tell a story. They tell the story for each position, looking at the record so that patient can have an appropriate continuity of care as they go through the health care system and the only way that our insurance companies know how we are doing, how we are performing is through the documentation and the coding. That is our communication tool to our providers and to our payers. And so, as we move away from E. And M. And P for service. We go into this value-based approach, where we are showing the quality of care that we are providing how sick our patients are, and really justifying the cost and the the amount of money that we take care of.

Daniel J. Marino:

Really and really tracking all the activities of really what has occurred with that patient, not just within that particular encounter, but really from a comprehensive standpoint, everything that's happened to them over, say the the duration of their care, if you will. 

Dr. Shah, how have physicians reacted to this? Do they see? that the improvement to some of their documentation. Not just improvement to some of their coding. But you know, with, Sarah said, being able to tell the full story, has this been something that they have been open to? Or has this been a challenge that they really needed to overcome? 

Dr. Shah:

Yeah, I think this is a really hard shift, you know, when you think about the ambulatory setting, you are talking about limited amount of time with patients who may be coming in for a multitude of illnesses. 

 Maybe that really needs some special attention to one or 2, and you are being tasked with capturing and documenting on all of their chronic illnesses. You couple that with the ambulatory space. We are really still focused on E. And M. Coding fee for volume and not really fee for value. I think it is a hard hurdle to overcome. 

I think what is really important, though, is when we are talking to our providers is, this is really the next phase of how we deliver care to our patients. It is really how we keep the lights on and get the equipment that we need to take care of them. And so, just as if there was a new drug for a chronic disease management that was having really good outcomes. We would all be excited to start prescribing that medication. We should be excited about the opportunity to really convey the quality of care that we are providing through our documentation. 

Daniel J. Marino:

Yeah, I agree. That is a great point and I cannot help (inaudible) you have been practicing for 25-35 years, right? Because they are used to really (inaudible) And now, all of a sudden, we are taking in these other elements into consideration. And so when you started your program and you started to really introduce this where did you start? Did you start with a couple of, say, disease categories like the chronic diseases? Or did you start with a segment of the population? you know, Dr. Shah! from your perspective what made the most sense for the physicians. 

Dr. Shah:

I think what really is helpful was starting with the why and really laying the groundwork. For here is why HCCs are important in our population health strategy. Here is what an HCC is. Here is how it impacts the reflection of the quality of care that we provide. By the way, it also impacts reimbursement and then we coupled that with some very basic tools in our EMR, and then from that, from that kind of just foundational understanding, we have added educational modules. We have added the ambulatory CDI process that you alluded to. And so that is really sort of been an iterative process of starting from a foundation of understanding why something is important, and then providing more and more tools and support and feedback to our clinicians about how they are doing and how they can improve.

Daniel J. Marino:

So, Sarah, when you started to consider some of the tools. And again, I am a huge proponent of technology, right? We have talked on this program many times that in order to really create efficiencies, you know we have to help our physicians work smarter, help them, not work harder, but become more efficient. Obviously, the technology and the tools help with that. 

 Where did you start? What are the tools that are out there that help support them in improving a lot of their documentation?

Sarah Hartley:

This is still a difficult thing, because tools are limited with the. 

Daniel J. Marino:

It is in the early stages of this. 

Sarah Hartley:

Right. So, we look to our Ehr, that is the main tool that our providers use, and the goal is to make it as easy as possible, reduce the number of clicks and the number of steps they have to take, and really embed our process into their day to day workflow. And then what can we help? What is the benefit that they are getting from us. So we looked at how the alerts fire in the Vpa. Can we make sure that those are accurate and we can add information in there for them to address the Hdcs with their patients. We have separated out the queries that we send to our positions because they get jumbled up in the rest of the messages. And what are the templates looking like? Do we have that phrases? Are there other tools in the Ehr that can be very easily accessible. That kind of help, the provider drive the elements of that documentation.

Daniel J. Marino:

Yeah. And really help them become more proactive. Right? I mean, you see this all the time. One of the reasons why physicians I think it's so frustrated is because there's just so much work that they have to do, and it is a lot of redundancy that certainly that they do not need to do, or somebody else could do, or they have already done it. So they are in baskets are huge, I think, as you start to put in place. What I'm hearing you say, is kind of those activities to help support the documentation activity will help them become a little bit more proactive and hopefully less in the burden. Dr. Shah, Is that been kind of a benefit that you have seen from the program?

Dr. Shah:

I think absolutely. And I think one of the really important parts of our program is that we are going to our clinic business meetings on a regular basis, and hearing feedback and sharing opportunities for improvement in many of the times we do are able to take that feedback back to our team and think about, how can we make something better? How can we make something easier for a clinician. 

How can we educate in a different way? are there ways to make this sort of come alive for our clinicians in a way that they are going to remember what we are saying to them. But I think that engagement is key. You cannot just set it and forget it with any improvement effort in quality, any quality, improvement effort. But I think, especially when it comes to documentation, which is added work on top of the work of caring for a (24:47) you have to be able to go back and provide feedback and say, Hey, I listen to you, and here is something cool that I can offer you, or Hey, I completely hear where you are coming from. I'm practicing clinician as well. And here is how I navigate this space, and how I am able to be successful.

Daniel J. Marino:

But what I am hearing you say though, is under the clinical documentation improvement program that you have in place. This is not just enhanced coding right? But it's really enhancing what is being documented being proactive and aligning it with the right level of coding. But understanding sort of what else has to occur right? Even outside that clinic visit. Is that correct?

Dr. Shah:

I would say it is really less about the coding and more about the documentation we can get to the codes. If the documentation is there. Physicians are not coders. We should not be. We end up, you know. That is not where our brain space, should be spent. 

 But we are experts at taking care of our patients, and we are experts at communicating to our patients how we are going to take care of them where the work needs to happen is translating the into the electronic medical record so that others can see how we are taking care of our patients. And then as positions. We get the credit for the work that we have done.

Daniel J. Marino:

Yeah, yeah, what has been the adaptability on this? I can imagine that this had to be really tough. When you first to introduce this right? I'm sure you have gota few scars and a few bruises. You probably both do. What was the adaptability of this? I mean, Did you find that physicians understood it, and that they were able to, you know, they sort of embraced it, or did they come to the meetings, little kicking and screaming, and saying, Oh, not really sure what we are doing. Or maybe this is just one more thing we have to do.

Sarah Hartley:

I think it's a mixed back. At the end of the day, our physicians are human, and it's hard, right? And so you have to speak to where they are at, and that in person, presence, and having those ongoing conversations has really helped taken the program to another level, where we have much more engagement.

Dr. Shah:

and I would say, the other part is that there are going to be people who are excited about it. There are going to be people who are able to see why this is important. And I would grab on to those people. Cultivate your excitement, you know. Bring them formally into the program. You know we have a team of physician advisors who are all very passionate about this. And I think it's something that sets our program apart. But if you find someone who is asking great questions, or sharing great ideas. Cultivate that enthusiasm as much as possible.

Daniel J. Marino:

Oh, yeah. Well, excitement like that, I mean, that's contagious, right? I mean, that's what kind of takes off. 

 If you're just tuning in on I am Daniel Marino, you're listening to value-based care insights. I am here with Dr. Shah and Sarah Hartley. We are talking about ambulatory clinical decision programs, key to navigating through value-based contracts. And Dr. Shah, as you were talking about that. I guess a couple of other thoughts came to mind. As you were thinking about the adaptability here. Did you incorporate this, or have you incorporated this in any type of financial incentive? In other words, if you have been able to achieve better performance on your contracts, have you included this within your incentive distribution model or rewarded physicians for higher adaptability, or something of that nature?

Dr. Shah:

We have included this as a part of our bonus metrics in primary care as well as in our medical group and some of our specialties as well. We understand that this is more work for all of our clinicians, and we want to reward them. 

 We want to make sure we are doing so in a compliant way, though. So that is why our program exists. We are really focused on the I in the clinical documentation integrity, you know, acronym. And so we are not just rewarding people for clicks and for adding diagnosis. We are doing it for adding accurate diagnosis and supporting the documentation. 

Daniel J. Marino:

Well, at the end of the day, I mean, those are the key drivers, because sometimes you can see, this is just like you said, adding more clicks or adding more codes or more diagnoses, or what have you and that have some impact to risk, and the wrap, score and all that stuff, which is, I guess, all good. But the end of the day. That is not going to get you where you want to go. We need to make sure that the risk score is accurate. We need to make sure that the patients that we are seeing and how we are seeing them either with the in the clinic or the referrals is efficient because it affects the cost of care. We also have to make sure that utilization is as efficient as possible. So I agree with you. I think the integrity piece is really key. and I think wrapping that within the incentive program. That is how you really really create some strong momentum. 

Sarah, when you have all started to align this or thought about this with the contracts. have you been able to see that the performance of the contracts, the connection between what the physicians have done, improvement in the documentation, so forth. Have you seen greater performance or alignment with the contracts and with the payers in a way that it's helped. Maybe the discussions you are having with the payers or something in that regard. 

Sarah Hartley:

Yeah, so I think the key one of the keys to being successful in this space is having those relationships with the payers, and we have monthly meetings with each of our payers, and we are seeing improvement. We are seeing our raft score increase. We are seeing a recapture rate increase year over year. you know, we are seeing our annual wellness visits increase. And so there is definitely an improvement as we move forward.

Daniel J. Marino:

Yeah, yeah, I can see that. So what about the challenges? I mean, I imagine this cannot be easy. Right? This is, you know, cannot be easy at all. It's a paradigm shift, like we talked about. We are introducing new things. Sarah, from your perspective. What has been the biggest challenge that you've had introduced the program and now have worked through the program. over these last period of time.

Sarah Hartley:

Oh, we are boiling the ocean here, I mean, we are just kind of scratching the surface. and you know primary care is a great place to start. But our specialists really have that knowledge to get us to that next level code that is really specific. So how do we get them engaged. We cannot put everything on primary care. How do we please? Every pay or all of the contracts are different. The report is different. We do not even get the same information from each payer. Do we have all of the claims data, right? And so there's all of this lag and these nuances with our metrics. With the data we receive. We have limitations with the technology. It’s every aspect, I will tell you. We have a challenge. It's with dapping. We firmly believe in training from the ground up because we are not going to find seasoned ambulatory  Cdi staff. And so we bring in people, and we train them from the ground up. And we have been very successful with that as well.

Daniel J. Marino:

Yeah, that's great. How about from your perspective, Dr. Shah what has been some of the biggest challenges that you have seen?

Dr. Shah:

I think the biggest challenge is that it is very hard to show the value of the work that is done in a way that feels immediate to a provider. It is really easy to say I treated your diabetes, and now your A1c is under better control. That's good for you as a patient, and it's good for me for my quality metrics. 

 When we talk about the reimbursement or the benefit that comes from Hcc. Capture and documentation. There is a huge lag like, Sarah said. It depends on what the contract is, how much it does. It depends on where the patient was seen and how that money gets distributed, and then at the end of the day it does not necessarily come back to an individual physician, so I think it is hard to convey to a provider. 

 Please trust me, this will have a benefit for us in the long run. and we have been lucky that we have a lot of folks who just kind of take us at our word, and we have to prove to them now that all of this effort is worth it 

Daniel J. Marino:

Yeah. Connecting the dots I think is always the hardest, especially in value-based care. When you are thinking about what your performance looks like. A lot of times you do not see that financial reward until after that performance here, and in most cases it is even 4 or 5 months after that because you are still going through all of the reconciliation. So you know, and in a lot of cases we are asking physicians to trust the process to get us to where we need to go. 

How has physician leadership come into play? You have mentioned that You had rolled this out to a number of physicians, and Sara had mentioned primary care and kind of rolling this out to the specialists. 

 Have you relied on more of the rank of file physicians within your network to drive this? Or have you really focused on creating? maybe working this through the leadership of your network. 

Dr. Shah:

I think we have really gone at it from both ways. You know, leadership engagement is so important for sure. And so we want to make sure that across the board that our leadership understands why this is important. But a leader alone is not going to get us where we need to be to support individuals. We need to support folks who are in the trenches and doing this every day. And so, while it is important to rally the troops when it comes to leadership and make sure that they can spread the message supporting and kind of cultivating. success really comes from our physicians who are doing this on a day to day basis. 

Daniel J. Marino:

Yeah, absolutely. Well, I can only imagine, this is a (inaudible) in terms of how we are dealing this thinking about changing the care model, as well as enhancing the documentation and being able to modify that culture, you have to rely on your leaders. But you also have to rely on good performance outcomes. Right? You have to measure your success as you go along. Sarah, have you? You know I would assume you have come up with some pretty good reporting, or at least some data, at least some information as a feedback tool, right that you can provide to your physician, your leadership?

Sarah Hartley:

Yeah, yeah, we do. We have very manual reporting at this point.

Daniel J. Marino:

the annual reporting. My goodness.

Sarah Hartley:

Yeah, yeah, I mean, we are. This I'm telling you in the industry. And we were just yet, we are not alone in this space. So, but using industry best practices like Http recapturing or query response rate is showing our providers that they are doing the right thing. We do measure wrap internally our risk adjustment factors for. And really, that is just directionally, because as you said earlier at the end, you know that 18 months ago, Today we are getting our raft score from 18 months ago. So you know, you cannot really see that. But it is directionally showing up.

Daniel J. Marino:

Yeah, yeah, I can see that. And you know I was kind of joking when you were saying Manual. You recaptureate the awv percentage. All of that, I think, becomes really key.  

But I think the system still are quite antique, right? As you start to really look at how, what the physicians are documenting, and is it accurate? Right?

Sarah Hartley:

And the population that you are measuring is very important. It is a subset of your overall. You know patient population that is just in these value-based care contracts. So you have to be very careful.

Daniel J. Marino:

Well, ladies, this has been great, I tell you, and I give you a lot of credit for embarking on this in a way that it sounds like you have built some good collaboration. And you know, understanding that it is a journey. And it is not going to happen quick. But it is something that is extremely important. 

Doc Shah, for any of our listeners, and I'm sure there's quite a few that are really giving consideration to putting an ambulatory clinical decision, improving the program in place. What advice would you give them? 

Dr. Shah:

So there is a quote from Wayne Gretzky that often gets thrown around when we talk about value-based care. You probably said it on this program before, but you have to get to where the Puck is going. You are not going to be successful if you skate to where it's been. And so I think you have to start talking about Hcc. Capture and documentation as part of your population health strategy. As soon as you identify the need to have a population health strategy, I think it's also really important to cultivate expertise amongst the folks who are going to be talking about this. I think on the surface of it. Hccs can seem really easy, and it's really easy to understand. I capture this condition, and I put down some documentation, and I'm good to go but once you really delve into it, there is a lot of nuance, and, as we know, increasing scrutiny as well, and so you do not want to be in a position where you have not enough depth of expertise to back up the work that you are doing.

Daniel J. Marino:

And I that is so critical and helping physicians particular understand why this is important and what the value is. Sarah how about from you? Any thoughts? Any piece of advice you can give to our listeners?

Sarah Hartley:

Do not be afraid to take a chance, you know a pilot is where you begin, and that is how you know, You just gotta get your couple of physicians to buy in and work with them and the pilot is the way to go. But have no fear.

Daniel J. Marino:

Yep, got to start somewhere. Right? Because I've said time and time again small and impactful. So you are right. Well, this has been fantastic. If any of our listeners are interested in, maybe reaching out to you. Have a few questions. Sarah, any thoughts on how they can get a hold of you?

Sarah Hartley:

Yeah, you can reach out to me. I am on Linkedin. So, Sarah Hartley, search for me, and I am out there. Please feel free to send me a message. Happy to chat.

Daniel J. Marino:

Good Doctor Shah. 

Dr. Shah:

Same thing. I'm on Linkedin. Purv Shah. Happy to connect with anyone out there. 

Daniel J. Marino:

Good! Well, thanks, guys, I really appreciate it. Good luck to you as you embark on this. I would love to have you back, and maybe another, you know, 6 months or so to see how your how you're doing, and I'm sure you're going to have quite a bit of success. So thank you for joining the program today.

Sarah Hartley:

Thanks for having me.

Daniel J. Marino:

and for our listeners. I want to thank you all for listening in until our next insight. I am Daniel Marino, bringing you 30 min of value to your day, Take care.

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners