Getting Paid For Value Starts and Ends With Clinical Documentation

Thriving under value-based reimbursement depends on capturing accurate measures of disease severity, says a former CMO.

Value-based reimbursement has come a long way since Anthony Oliva, MD, was implementing a gainsharing program at Kalamazoo, MI-based Borgess Health, a three-hospital system owned by Ascension Health, the nation's largest nonprofit health system, in 2011.

In two short years, the health system was able to transform its quality and safety measurement amidst a big push for physician employment that saw the health system grow from 50 to 300 employed physicians.

The use of quality metrics as part of its gainsharing program was aimed at medical staff engagement, case management improvement, and reputational improvement for the organization as a whole as much as it was about physician alignment, Oliva says.

Under that program, and following the prescriptive rules of the Office of the Inspector General around gainsharing arrangements, Borgess was able to take incentive dollars from Blue Cross Blue Shield of Michigan and pay physicians for their support of quality outcomes. Those outcomes were dependent, at least to a significant degree, on appropriate and detailed clinical documentation.

"We worked with our independent physician organization on quality metrics that would allow us to pay the physicians from that Blue Cross money for their support of quality outcomes at the hospital," says Oliva.

The problem: "The OIG is very intrusive with the paperwork required," he says.

It was cumbersome, to say the least. "It was all based on inpatient, with lots of measurement requirements, and physicians had to pay in to become part of this group," he says.

Since Oliva left Borgess in 2013, gainsharing programs—always ungainly and uncertain in the best of times—have largely been replaced by accountable care organizations at most organizations that are trying to get a handle on value-based care. ACOs are all standardized, making shared savings incentives a little easier to administrate.

Bad Data. Bad Outcomes.
But the core principles of collecting accurate patient data, and critically, acting on that data in a timely manner, are the same as they were in gainsharing. Bad or incomplete data means likely failure to achieve better outcomes, higher levels of safety, and higher levels of efficiency.

"If you can do a very good job of capturing your population both in severity as well as capturing the appropriate outcomes—and there's methodology that can help you do that—you can win at that incentive game. If you don't, you're going to be falling short and wondering why, because at the end of the day, people who do a good job of capturing metrics and data and performing interventions based on metrics and data, are the ones that are going to win," Oliva says.

Now vice president and chief medical officer at Nuance, a company that develops and market speech software for use in clinical documentation, Oliva says organizations that are laissez-faire in such data collection and usage are going to lose.

"You have to work to make sure you're truly capturing all those metrics," he says.

The biggest key to success under bundled payments and other value-based schemes is, as it is with fee-for-service, capturing all the necessary information to diagnose how sick, how severely ill, your patient population is, he says.

But not for the same reasons.

Whereas with fee-for-service, comorbidities and severity are closely associated with direct payments for services. With value-based reimbursement, it's all about setting the proper baseline risk for the population for which you're responsible. Otherwise, bonuses are all but unreachable. It can all seem pretty game-based, but Oliva says many organizations unintentionally understate the acuity of the population because of poor or incomplete clinical documentation.

Measuring Severity Pays
"The sicker it looks, the more you'll profile better in the outcomes, so that's a big piece," says Oliva. "All the measurements start with the risk of the population, and outcomes don't matter if your baseline's wrong."

For example, if your organization has a 2% mortality rate and the expected mortality of the population is 4%, you're doing really well. But if you don't do a great job of documenting illness severity and as a result your expected mortality is measured at around 2%, achieving 2% makes you look somewhat average.

"That has to be the starting point," Oliva says. "You can never drive outcomes down to a level that's below an already unrealistic view of the severity of the population." That's because the majority of outcomes are based on the disease burden and how it's measured, not your performance, he says.

It's a simple concept, but it's often not easy to understand that the baseline comes largely from proper and complete clinical documentation so that initial baseline can be accurately measured, he says.

Do you have a comprehensive clinical documentation improvement program that you can operationalize?

"If you haven't done that, you're already starting too late," he says. "There's such a delay in data. You really need to be starting now because it takes so long for that to be crunched. I would be petrified to go into a risk contract where I wasn't sure I was doing everything possible to capture the severity."

That's how payers have historically controlled the risk pool, Oliva says, to highlight the importance of severity.

Oliva says many organizations don't recognize the importance of this issue because the downside risk to the overall organization is currently not high, on average. Right now value-based purchasing sits at a meager 4% of revenue, though that varies widely geographically, he says. Fee-for-service, not value, still overwhelmingly drives revenue. But the tipping point will occur, and it gets closer every day.

"There's money on the table today, but it's not overwhelming. But by 2020, where 50% of reimbursement is value-based, that's a game changer," says Oliva. "You should be doing clinical documentation improvement right now, because it will help you win in fee-for-service too, but the added benefit is that it's setting you up for that new environment."

The biggest risk factor around clinical documentation improvement is to just assume you have a good program because you have people doing this work, he says.

"It's too easy to say, 'oh yeah, we do that,'" he says. "But are you measuring it, benchmarking, recording things that are vital, and dealing with lags on a diagnosis? Those are the types of things that are the biggest dangers in organizations that think they are doing this well, and really aren't."