Regulatory
Stances & Shifts
Stances & Shifts
How many patients are losing healthcare coverage as a result of the "Big Beautiful Bill"?
~11-13M patients
A provider _______ is someone who will help gain peer buy-in and shift mindsets / action to align more broadly with VBC.
Champion ** instrumental in broad success
What are the types of contractual "risk" that providers can take on?
Upside - can only benefit (low risk, low reward - e.g. MSSP track 1)
Downside - might need to pay if performing poorly, might also get extra compensation if doing well (high risk, high reward - e.g. global capitation)
What is attribution in VBC?
The assignment of responsibility for a patient's care. Responsibility can be assigned either at an Org-level (TIN) or Provider-level (NPI).
These two "T" words are fundamental to operational success in VBC. Data t_______ and t________.
Transparency & timeliness.
(Also, transparency = trust)
Which part of CMS (Centers for Medicare & Medicaid Services) is focused on testing new healthcare payment and service delivery models?
Center for Medicare and Medicaid Innovation (CMMI)
Patients seeing in-home providers are X% less likely to go to the ED (per Arkos Health)
20% less likely
How is "Value" defined in VBC?
High Quality @ Low Cost
Quality == outcomes + experience
Cost == direct + indirect
True or false: All insurance payers offer the same level of attribution information to healthcare providers, as part of value-based care contracts.
False - this is based on payer type (gov vs commercial), readiness / sophistication, willingness, and ultimately contract terms (as negotiated by the provider group & payer)
Many payers operating on (scarily) ancient tech (but that's no excuse in this land of accountability)
Rising Risk
What two themes are the Trump administration focused on, related to improving VBC?
Cost and (Quality of) Outcomes
(Foundation is "protecting the federal tax payer")
This type of appointment occurs every year, and serves as the basis of understanding and engaging patients within Value-Based Care
Annual Wellness Visit - "Do I have the data I need to treat? Do I have the data to perform?"
What component of ACO REACH is not required in MSSP?
Equity - helpful, but only mandated in REACH (also recently changed)
True or False: the payer has complete say over which patients make it into the "attributed population".
False! This is part of contract negotiation (depending on the type of arrangement)
What is the 80/20 rule, and how does it relate to AI opportunity?
80% of time is being spent on things that produce 20% of the impact - these are prime candidates for automation & ai agents
We want users to be able to spend time on activities that are broadly impactful
What two themes were the Biden administration focused on, related to improving VBC?
Access (Coverage) and Equity
What type / set of information helps providers identify potential barriers to patient care?
Social Determinants of Health (SDoH)
What does "TCoC" stand for?
Total Cost of Care
This type of attribution exists based on the reality of care being provided to a patient; it is not defined by the payer.
"Functional", "Calculated", "Internal"
This type of value-based payment model is becoming increasingly common in specialties like Orthopedics, where payment is given based on expected care for an entire "event".
Bundles (e.g. knee replacement includes imaging, procedure, PT, etc...)
What practices / areas of focus are aimed at improving cost and outcomes, per the current administration? (3 answers)
Avoiding disease occurrence (prevention) ...?
Early detection
Disease management (progression)
Five chronic disorders account for 75% of direct medical care costs in the US - what is the fifth chronic disorder?
Diabetes, Congestive Heart Failure, Coronary Artery Disease, Asthma, and ________________
Depression (impact on TCoC, need for coverage)
Which VBC contract types care most about TCoC?
Bonus: Why?
Shared Savings, Capitation
Bonus: reimbursement structures are based specifically on expected vs real cost - i.e. based on the population's risk level, they are expected to cost $X. Anything below that cost means extra money for me / my provider organization.
BCBS assigns patient James to Dr. Mukesh as his PCP.
James goes and sees Dr. Mudit instead for a PCP visit.
There is also evidence of James seeing Dr. Smith for a PCP visit.
Who is James's attributed PCP?
It depends... any / all of these providers depending on viewpoint. These are important to look at together!
Payer-assigned PCP = Dr. Mukesh
Internal / functional = Dr. Mudit
Calculated = Dr. Smith
What does "NLP" stand for and how does it relate to AI & VBC?
Natural Language Processing
AI is able to "read" handwritten notes to decipher meaning and associate with a patient (part of the "whole patient" / longitudinal medical record)