For primary care practices serving Medicare beneficiaries, embarking on a value-based care (VBC) journey means rethinking traditional approaches to care and reimbursement.  Transitioning from fee-for-service to value-based models requires a focus on outcomes, efficiency, and care experience. The following guide outlines some key considerations to keep in mind.

PRIOR TO GO LIVE:

1. Learn, Assess, Prepare, Test

Understand Medicare Value-Based Care Participation Options

  • Learn the nuances of available Medicare Value-Based Models and choose the right entry point (Medicare Shared Savings Program (MSSP) and ACO REACH).
  • Assess participation and potential impact on your practice.
  • Compare potential ACO partners based on: shared savings rates and caps; projected savings; reporting and support services; quality performance; and participation agreements.  Share data with prospective ACOs to customize proposals and optimize your participation strategy.
  • Stay informed about annual application and participation deadlines to ensure timely enrollment and compliance. 

Assess Internal Investment Requirements

  • Use Certified EHR Technology (CEHRT): Ensure that EHR systems meet program requirements, including promoting interoperability, ACO beneficiary flagging, and ACO quality metric data capture and reporting.
  • Data Exchanges: Confirm capacity for sharing billing, quality, and EMR chart access with the ACO and any associated vendors.
  • Internal Team Structure: Identify an interdisciplinary team composed of clinical, quality, operational and financial champions to regularly engage with ACO staff to execute on VBC goals within your organization.
  • Align Practitioner Compensation: Align practitioner compensation and incentives with value-based goals.
  • Prioritize VBC Workflows: Integrate ACO attribution, quality, and clinical work into practice workflows to close gaps. Leverage ACO reports to identify key areas for performance improvement, and implement process improvement to address root causes.

2. Select ACO Partner 

3. Implementation Planning for January 1st Go Live

  • Establish your internal VBC team.
  • Educate staff/practitioners on VBC fundamentals, goals, and success metrics before the start of the Performance Year.
  • Participate in ACO onboarding sessions.
  • Establish and test data feeds.
  • Identify your ACO-eligible patient population and ‘flag’ them in your EHR.
  • Ensure that ALL billing is aligned with TIN participation requirements.
  • Understand Year 1 priorities and timelines based on input from your ACO partner.

YEAR 1 PRIORITIES: 

  • Validate Data Feeds Early: Ensure data feeds are established and working early in performance year.
  • Attribution Optimization: Prioritize early “anchoring” visits to solidify attribution and secure plurality.
  • Early Quality Touchpoints: Complete initial screenings (e.g., depression screening at anchoring physician visit) as early as possible – especially for high-risk beneficiaries.
  • Address Gaps in Performance: Leverage ACO-provided resources and support to identify and close gaps in attribution, documentation, and outcomes.
  • Target High-Risk Populations: Focus care management on beneficiaries with high hospitalization risk using proactive visits and strong transitions of care.
  • Documentation & Coding: Begin efforts to optimize documentation and accurate risk capture (e.g., HCC coding and risk adjustment).

YEAR 2+ PRIORITIES:

  • Accelerate Anchor Visits: Push attribution and quality actions earlier in the performance year.
  • Growth: Focus on continuous improvement in outcomes and quality documentation.
  • Optimize Workflows: Refine team-based workflows to better support your VBC initiatives.
  • Advance VBC Culture: Cultivate a team-wide commitment to value and dedicated care.
  • Enhance Care for Advanced Needs: Introduce or expand care model for advanced needs, such as Drive to Deprescribe.
  • Evolve Risk Adjustment Practices: Continuously optimize risk coding and documentation processes.

Take the Next Step Toward Value-Based Success

The journey to success in value-based care isn’t linear. It demands investment, collaboration, and an ongoing commitment to improving outcomes. By following this structured approach, your primary care group will be well-positioned to deliver higher-quality care, drive efficiency, and maximize performance in Medicare’s evolving value-based landscape. Now’s the time to invest, align, and lead.

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