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Part 2 of “Helping Physicians Overcome Barriers in Risk-Based Documentation and Coding”

In part 1 of our blog series, we laid out three soft signals that your physicians may need additional training in risk adjustment documentation and what each signal can indicate about the root-cause barriers your physicians are facing. Now that we’ve shed some analytical light on the problem, let’s turn to solutions. What are some effective ways to empower peak physician performance when it comes to risk-based documentation and value-based care?

We know what you’re thinking; our answer must be that physicians need a sophisticated, AI-infused IT solution with a ‘data minimalistic’ interface that avoids overwhelming the team. And yes, we do think that’s true and it happens to be what Curation Health offers.

But for today’s discussion, we’re putting our own business imperatives aside. Instead, we will focus on the following “soft solutions”; training, communication, and leadership tactics– to help smooth the physician’s path to value-based care.

Foundational Competency: Physician-led Training

All of the best practices recommended below hinge on an organization’s overall competency in physician-led trainingPeer leadership is critical to helping medical staff work through the discomfort of change. 

Successful peer leadership can take many forms, from engaging more designated physician champions to act as guides, to repeatedly holding peer discussion panels designed to diversify provider education.  The must-do: Give the spotlight to physicians who have successfully made the shift to VBC-centric thinking.  Ask them to share areas of discomfort they experienced early in their VBC journeys, as well as the tools and mindset shifts that were ultimately important for unlocking personal performance.

Best Practice #1: (Re)teach the Concept of PCP as Central to the Total Care Plan

We previously discussed how early on in client engagements with Curation Health, primary care physicians will ask questions such as: “I’m not an oncologist, why am I seeing this cancer code?” and, “Why do I have to consider this behavioral health condition if the patient is also being seen by a behavioral health specialist?” These questions reflect the discomfort that a reasonable, fee-for-service-trained PCP may have when asked to capture the total complexity of care.  The root-cause organizational barrier behind this concern tends to be insufficient training on the concept of PCPs being the ‘quarterback’ of the patient’s total care plan. 

To be fair: All organizations that engage in value-based care have almost certainly already trained these same physicians in the concept of PCP as ‘Quarterback of Care’. So what more is there to be done?

The answer lies in remembering that value-based care is so substantially different from the way most physicians were trained and have practiced that it can take a few different times–paired with the peer experience angle–for the concepts to fully sink in.

The two key ideas for peer leaders to reinforce are the PCP’s role:  

  • At the center of patient care
  • As the leader of the care team

These are both great topics for peer panels and presentations. They are also threads that can be woven into addressing more specific questions and concerns, as outlined below.

Best Practice #2: Outline Appropriate PCP Roles in Risk Adjustment Activity Related to Specialist-Diagnosed Conditions

In addition to the general challenge of quarterbacking the patient’s total care plan, risk-bearing organizations must also address the PCP’s specific challenges with documenting specialist-diagnosed conditions–a make-or-break element for thoroughly documenting risk factors.  

To help a newer-to-risk PCP make this transition, ask your most experienced, risk-savvy PCPs to discuss their personal challenges and lessons learned in dealing with ‘specialty’ diagnoses as part of the total picture of patient care

  • How did they learn to document in ways that captured the complete context of the patient’s health?
  • How did they begin working differently with specialists to achieve better patient results? 
  • What education and/or tools were helpful in terms of getting more comfortable understanding their role(s)?

Your own risk-savvy PCPs can generate many useful talking points that all peer leaders can use in addressing newer-to-risk physician questions.

Helpful Talking Points Regarding the PCP Role in Risk-Adjustment Activity Related To Specialist-Diagnosed Conditions

For all PCPs

It is not at all accidental that specialist-diagnosed codes are showing up in primary care settings. Consider the patient’s particular health goals, whether it’s helping them remain mobile, or keeping them out of the hospital, or keeping their A1Cs low. If you start with that view, a broad range of diagnoses historically considered to be the domains of other specialties become highly pertinent to the primary care and patient support you are providing.

For PCPs of cancer patients, specifically

You have no doubt experienced how, under fee-for-service, there’s long been a missing link between cancer care and primary care. If we pull cancer diagnoses into the total clinical picture to be managed for our patients, that helps us provide services that reflect their actual needs. For example, a particular regimen of screenings in light of elevated risk factors, such as a history of cancer.

For PCPs of behavioral health patients, specifically

You can and should enlist and coordinate with Behavioral Health Specialists as needed. You do NOT need to perform the initial behavioral health diagnosis to account for the diagnosis in your care plan. You know from experience how treatment plans are likely to fail if they don’t take into account the patient’s bipolar disorder, substance abuse disorder, or depression–that’s why this is now part of the information picture about patients.

Best Practice #3: Contextualize the Need to Document Certain Non-HCC Conditions for the Patient’s Benefit

In Part 1, we discussed that when Curation Health first begins working with an organization, we often hear physician comments that reflect some variation of, ‘Why am I seeing this code for hypertension when it’s not an HCC?” When that happens, the root-cause problem may be that that previous risk adjustment training focused too much on ‘teaching to the test,’ leading physicians to believe, incorrectly, that their role in risk-based documentation and coding is limited to capturing Medicare HCCs. That impression creates a dangerously narrow view of the provider’s clinical role, as well as an unwelcome compliance risk. 

To help physicians who may have this misconception about risk-based documentation being ‘all about HCCs’, peer-led education should focus on the non-obvious ways that non-HCC conditions support patient care and accurate risk adjustment. Specifically: Certain non-HCC conditions must be considered simply because they indicate important clinical context for the patient – regardless of reimbursement model.  

Helpful Talking Points for Physicians Regarding The Need To Document Non-HCC Conditions

You’re right, hypertension is not associated with an HCC and does not have risk adjustment value. But even so, it still factors in some ways into risk documentation and coding.

In some cases, confirmation (or dismissal) of hypertension plays a role in identifying a more specific code for another clinical condition that is an HCC. For example, if CHF and hypertension are occurring together, this opens the question of whether a more specific CHF code and or more aggressive care management are called for.

Hypertension does not in itself directly affect the risk adjustment factor in Medicare value-based care programs today. Incidentally, this may change in future, as it does affect risk adjustment specific to pharmacy, which may become a part of physician-facing value-based care programs in future. But more important is that, as you know, hypertension drives outcomes for the patient. Even if it had no direct impact on risk adjustment or any other value-based care metric, it’s critical to reflect in documentation and the total care plan.

For example, you can imagine how unmanaged hypertension is an important indicator of rising risk of diabetes, or if in a patient with diabetes, of risk for diabetes with complications.

Under value-based care, the PCP’s role is to keep the patient’s overall risks low, and managing hypertension is an important part of that picture.

Best Practice #4: Address Areas Where the Longer-Term Patient Care Imperative May Clash with Short-Term Patient Relations

Often, when physicians systematically under-document conditions known to be prevalent within the population, the root cause tends to be physician discomfort dialoguing with patients about long-standing health issues that carry some stigma. The most frequent example of this is morbid obesity – a common condition nationwide and a diagnosis we often find to be missing in risk-based documentation and coding. 

To address physician discomfort, a variety of supports may be needed, including additional peer-led training that specifically targets patient-relations concerns that physicians are experiencing. 

However, training alone will not be enough. Persistent physician discomfort with the transition to risk can be a symptom of a larger organizational issue related to supporting physicians. That is why our best practice #5 is about creating the right operational and delivery model context to support physicians in delivering value-based care.

Helpful Talking Points for Physicians Concerned About Raising Sensitive Issues with Patients

You’re capturing this as a chronic condition that you are actively managing – one that is going to drive quality outcomes, cost, and utilization. The resources you get for managing this patient come from the information you’re capturing. You are communicating to payers ‘This is a complication I am managing.'

We believe that patient experience ratings are an important metric. And, we can protect those ratings by having difficult conversations and setting the right expectations with patients – for example, by explaining that ‘annual wellness visits represent 60 minutes of guaranteed time to look at you holistically, without any specific chief complaint.'

We know this is a challenge; we believe it’s worth it to tackle this because it lays the foundation for improvement of health and quality of life.

If patients make negative comments about you because of these types of difficult conversations, those comments will not be considered a reflection on you. This organization understands the context and we will support you.*

We have a policy that complaints like these will not affect promotions or your compensation.*

* These last two talking points are dependent on having specific supporting policies in place, which brings us to our concluding thought about supporting your physicians.

Best Practice #5: Go Beyond Training – Evolve the Delivery Model to Support Physicians on Their Path Toward Risk

Even the most thorough peer-led training will fall short in helping physicians overcome barriers if the organization as a whole does not fully adopt all the changes to the delivery model needed in order to succeed under value-based care.

For this reason, consider putting in the operational changes and resources that your primary care physicians will need – so that your physician champions can highlight them in their discussions.  

Example Policy/Resource Changes to Address Challenging Areas in Value-Based Care

• Reduce panel sizes so that PCPs have adequate time to manage each patient
• Increase appointment slot times, particularly for annual wellness visits, so that conversations are not rushed
• Create policies that protect physicians from unwarranted negative impact of patient complaints (presuming those complaints stem from constructive, but difficult, conversations about long-term health goals)
• Ensure an adequate supply of physician champions to address challenging aspects of the transition to value-based care

At the end of the day, masterfully navigating the transition to a risk-based environment is not solely about IT and analytics,  training and communications, or delivery model changes. A thoughtful and committed approach to all three is the only surefire way to set up physicians, and consequently organizations, for greater success in value-based care.

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