We are seeing a shift away from acute care treatment in favor of lower-cost outpatient or ambulatory care settings, due largely to the transition from volume to value-based care. Hospitals are working to decipher the most appropriate care setting while maximizing quality outcomes, minimizing performance penalties and optimizing financial reimbursement. Given this shift, and the need to uncover revenue in the ambulatory setting, we surveyed 130 healthcare professionals (senior leaders, clinical leaders, operation leaders and IT) to uncover drivers, challenges and risks.
Provider organizations understand the importance of increasing outpatient revenues; it’s a top-of-mind priority among senior health system leaders. It’s managing the differing clinical documentation, coding, billing and payment methodologies requirements and strategies that make optimizing this critical source of revenue so daunting.
Physician practices & quality-based payments
Nearly two-thirds of leaders surveyed said improving outpatient care delivery and revenue, while transitioning to value-based payment (VBP), is a strategic imperative. Many also said the inability to recognize risk versus opportunity presented a significant challenge for them. They cited insufficient support for physician practices in documentation, coding, and billing as one of greatest challenges to optimizing outpatient revenue integrity and compliance.
These concerns are not unjustified. Appropriate and specific documentation leads to correct coding, and is essential to accurate disease burden capture and carries implications for quality-based payments and population health management. Together, these are critical to preserving revenue integrity and transitioning to new payment models successfully.
We find our clients who tackle ambulatory CDI programs are adjusting to the wide range of documentation, coding and billing requirements in the outpatient arena and how they differ from the inpatient setting. Higher patient volumes and shorter encounter times – not to mention a shortage of qualified clinical documentation specialists trained in the unique payment methodologies in the ambulatory space creates a scary situation. With all these uncertainties, you can see why healthcare leaders look at ambulatory CDI as the Wild, Wild West. This is particularly true as it relates to risk-adjustment payment methodologies.
This explains why our research found outpatient care delivery and reimbursement a top concern; leaders understand that this “Wild West” can have a very negative impact on overall clinical and financial performance for an organization.
It comes as no surprise that nearly an equal amount of the survey respondents (62%) mentioned pressure to transition to VBP and better population health management (58%) as key drivers to their outpatient revenue priorities. The Department of Health and Human Services (DHSS) is watching this closely; this year 85% of all Medicare fee-for-service payments will be tied to quality and value, and by 2018 the agency will tie 90% of payment to this these metrics.
In addition to working with clinical teams, I work closely with healthcare CFOs. Financial performance is always at – or close to – the top of their list of business objectives. These leaders also are looking at risk-sharing models that link the cost and quality of care with shared savings, as they are a principal contributor to financial success.
The transition to value is taking hold. There are a number of things leaders can think about and prepare now that will help set them up for success and mitigate risks.
Read the full survey report, Taming the Wild, Wild West of Ambulatory CDI to Enhance Overall Hospital Revenue Strategies, here.