Are You Risk Ready? – Transitioning to Value-Based Care

Written By:

Kathy Ormsby, CPC, CPCO VP of Compliance and Analytics

September 2020



The transition path away from the traditional Fee-For-Service (FFS) reimbursement to a value-based care (VBC) model is now almost 20 years in the making.  The pace of change, while slow at its outset, has in recent years accelerated to a point that now requires all healthcare providers to establish new routines, systems and programs to accommodate new and ever changing regulations issued by the Center for Medicare and Medicaid Services (CMS).  While the focus switches to VBC, as part of this transition process, current CMS regulations also incorporate incentive payments or penalties, coupled with risk adjustment calculations applied to traditional FFS Medicare patients as well.  In addition, this shift not only includes changes to the way primary care providers deliver care but has a substantial impact in specialty medicine as well.  Consequently, this subject is pertinent for all providers no matter the specialty of the practice or the level of risk currently assumed.

At present, providers can apply for participation in specific value-based programs designed for their specialty. This may be voluntary today but will be the required reality for healthcare providers in the very near future.  To remain competitive and profitable in this ever-changing market, providers must change their focus from quantity of care to quality of care.  Included in this shift is a comprehensive understanding of the concept, application, and calculation of risk adjustment and how this will impact the entire Medicare population.  This blog will guide organizations towards best practices in adopting the value-based model and discuss the following keys to success in the transition:

  • Develop an appropriate and detailed action plan
  • Understand the organization’s population health attributes
  • Identify processes, technologies and workflows that will require change
  • Select the appropriate model and level of risk
  • Accurate and timely measurement of Key Performance Indicators

Get Ready

Transitioning to value-based care requires a dynamic philosophical approach including the design and implementation of new technologies, processes, and workflows.  As just one example, some VBC models require Hierarchical Condition Category (HCC) coding for risk scoring calculations, this was not included in the traditional FFS Evaluation and Management (E & M) coding providers have relied on in the past.   To further complicate the new environment, E & M coding will still be necessary in a VBC environment.  Without adequate preparation and training, organizations may not receive all the revenue they appropriately deserve or conversely, create exposure for substantial penalties for regulation violations.  In addition, improper implementation may impede an organization’s ability to avail themselves of the numerous financial incentives available.

Prior to embarking on a VBC program, organizations should assess their current status to understand training needs, process changes required and technology tools available to assist.  Key Performance Indicators (KPI’s) and goals should be established to ensure success.

The qrcRiskReadiness Assessment™  platform is an automated assessment protocol to help organizations develop an appropriate plan before embarking on a VBC model; the assessment will answer all the proper planning questions while also provide solutions to each of the known barriers to success see “Transition to Value-Based Care” white paper located here.

Get Set and Go

Once an assessment has been performed and the path to implementation has been identified organizations should find a suitable automated solution to help manage the process.  An analytics platform is necessary to perform accurate and timely measurements of the selected KPI’s and quality metrics, one of the keys to success identified in the introduction above.  Using analytics to measure, track and analyze the organization’s patient population will enable the development of specific (including patient specific) and relevant action plans that will provide optimum health care as well as financial results.  The analytics platform should be able to identify and analyze:

  • Gaps in care
  • Clinical opportunities within the patient population
  • How and where dollars are spent
  • Utilization rates
  • Coding compliance and optimization

In addition, the analytics platform will help the organization adjust its KPI’s and quality metrics to those that are most appropriate for the treated population.  Understanding the organization’s patients and its patient population is the foundation of value-based care.  Proper analysis of patient care and treatment will help identify the patients that are driving health care cost which is often a result of fragmented care, a common cause of increased cost and lower than expected care quality.  The use of point of care tools can reduce such variations and will enable providers to choose the best treatment and specific diagnosis most relevant to the individual patient.  Use of the data analyses from the software tools mentioned will result in increased engagement and involvement of the provider care team, a critical factor for success in VBC and will help manage the many and complex success factors in VBC


Value-based care is on the rise.  A report released in 2018 by the Health Care Payment Learning & Action Network indicated that 34% of payments to healthcare organizations were tied to VBC with steadily increasing rates over the prior two years.*  That rate is expected to increase at a higher rate than the increase in the Medicare population over the next 5 years.  The transition is complex and time consuming; a haphazard implementation can have a catastrophic impact for the organization.  Therefore, adequate planning and the selection of the proper analytical tools will ease the burden while ensuring success in this new environment.

Since its inception, qrcAnalytics has been a leader in the movement to value-based care for both primary and specialty care providers. Our tools are oriented toward total population health management and resolve every area of concern indicated in this paper. Included in our offerings is a distinctive qrcScore™ which identifies the organization’s quality, risk, and cost of care. This score enables provider organizations to better understand and manage each area of the qrcScore™. Our implementation is a seamless process, resulting in a positive end-user experience which empowers the user to work smarter, not harder.  qrcAnalytics believes that data without context is just noise.

Contact us for a qrcRiskReadiness Assessment™ and receive your unique qrcScore™ today.


*Health Care Payment Learning & Action Network