With a newly elected president and a GOP-controlled Congress, the future direction of healthcare policy is uncertain at best. But one fact remains true in any political environment: Every chance to close gaps in medically necessary care is an opportunity for providers to realize incremental revenues while doing what is right for their patients.
Closing care gaps can often help providers who are focusing on care coordination and quality improvement to optimize their fee schedules under various value-based reimbursement models, including MACRA and commercial pay-for-performance programs. As a result, developing and gradually augmenting a care gap program is an increasingly attractive way for provider organizations to initiate their population health management (PHM) efforts while they are generating a majority of their revenues under traditional fee-for-service (FFS) contracts.
Trying to simultaneously navigate muddy healthcare waters and bridge the gaps in care for patients, but don’t know where to start? Start at the beginning—establish a care gap program.
What a Care Gap Program Entails
Under a care gap program, provider organizations:
- Identify high-priority populations to focus on.
- Choose critical components of care for these populations.
- Create processes to routinely and consistently deliver the critical components of care.
- Agree on expectations (e.g., targets) for the established clinical protocols.
- Monitor performance.
- Intervene to improve performance as necessary.
In most cases, the foundation of a care gap program is proactive engagement—for patients (e.g., outreach) and providers (e.g., education, performance reporting).
Care Gap Program Development
Establishing a care gap program should not be a monumental undertaking for most provider organizations. For some time, hospitals and physician practices have worked to identify and close care gaps, within the value-based payer modifier program in the inpatient setting or the PQRS program in ambulatory settings. Provider organizations can successfully capitalize on this experience and scale the technologies, processes, and resources developed to participate in these programs in order to address a broader array of care gaps for an increasing number of beneficiaries across various payers.
Better Quality, New Revenue
One of the hallmarks of effective PHM is providing evidence-based, medically necessary care before the deterioration of a patient’s health status or the occurrence of an acute adverse health event. A care gap program enables providers to do exactly that—and receive additional revenues for doing it successfully. The impact on reimbursement is typically at least twofold:
- When providers bill for additional services to close gaps in medically necessary care, more revenues are captured.
- As care gaps are closed, performance in relation to governmental (e.g., MACRA) and commercial (e.g., pay-for-performance) contracts is improved, and in turn, realized fee schedules are increased.
The Usual (Care Gap) Suspects
Many time-sensitive screening, preventive care, and health maintenance interventions should be considered as gaps in care (for patients who don’t get them). Examples include the following:
- Outstanding pneumonia and influenza immunizations in the elderly population
- Pending screening exams for cancer (e.g., breast, colon, prostate) or chronic disease (e.g., diabetes, hypertension, osteoporosis)
For a provider organization’s Medicare patients, one of the biggest revenue-generating opportunities for care gap closure may be the Medicare annual wellness visit. This is a reimbursable visit with no cost to the patient during which a number of care gaps can be addressed efficiently. According to current statistics, roughly 12% of eligible Medicare beneficiaries take advantage of this visit, which makes it a significantly underused vehicle for closing care gaps.
Potential Challenges
Provider organizations that clearly initiate their PHM efforts by focusing on care gap closure create an opportunity to generate incremental revenues while simultaneously improving the quality of patient care. However, common obstacles can arise when trying to establish an efficient program that proactively addresses care gaps. Table 1 shows some of the obstacles that providers encounter when initially implementing these programs and some ways to overcome them.
| Challenge | Tactic |
|---|---|
| Identifying Appropriate Patient Cohorts | Use analytic systems to identify patients with specific care gaps or eligibility for a Medicare annual wellness visit. |
| Automating Patient Outreach | Activate patient portals or other automated communications to conduct outreach campaigns to groups of patients needing specific care. |
| Handling Additional Work | Use a portion of the anticipated incremental revenues to hire a care coordinator. Focus this resource on enabling efficient care gap closure (both personally and in support of other practice providers). |
| Understanding the Impact of Quality Scores | Deploy a process (manual) or system (technological) that will track care gap closure and quality scores by provider over time. Review and discuss trends and outliers in regular practice and clinic or department meetings. |
The Bottom Line
Closing gaps in care benefits patients and the providers who treat them. Even with significant uncertainty related to the future of healthcare reform, provider organizations should develop care gap programs that will result in better patient outcomes and increased revenues under either value-based or FFS reimbursement models.
Want to learn more about using FFS strategies to participate in quality-focused Medicare programs? Check out Building a Fee-for-Service Bridge to Population Health in the November 2016 issue of hfm.
Published April 26, 2017