As compensation becomes more closely tied to value-based care, it behooves physicians to develop new strategies to care for their sickest patients.
Increasingly, Medicare payments are tied to the value and quality of services provided, which means that as physicians we must consider new approaches to caring for patients who are most at risk. It sounds great in theory, but how does it affect the way we actually care for Medicare patients?
When your practice assumes the care of a Medicare population under a value-based agreement, it can be a challenging endeavor. The Medicare population is expanding rapidly and some enrolled in Medicare will require a highly personalized level of care. Here is a five-step approach to assist primary-care physicians as they develop strategies to best manage their population of Medicare patients in value-based arrangements.
A 2012 CMS survey found that more than two-thirds of Medicare recipients had at least two or more chronic conditions. But there are several warning signs that can help you evaluate who the most fragile and high-risk patients are. If you do not have access to predictive models for your patient panel, here are some factors which can help you identify which patients are at high risk:
Providing easy access to care is key to managing high-risk patients and keeping them out of the emergency department. The following steps can help:
To help prevent future hospitalizations, ER visits, and other health complications, it's important to educate the patient and any caregivers so they can identify the signs of an emergency or decline in health. Arming patients with this knowledge helps them take charge of their own wellness. During appointments, consider discussing the following topics with both patients and caregivers, and offer them educational materials for in-home use to reinforce the information regarding:
Some proportion of your Medicare population will need services outside the scope of traditional primary care to help them and their caregivers properly manage specific health conditions. To coordinate holistic care for elderly or fragile patients your practice may need to engage outside services to:
Hospital readmissions are unpleasant for your patients, are expensive, and may place your patients at increased risk for morbidity. Many hospital readmissions can be avoided if you:
Providing high-quality care to fragile Medicare members requires an entire ecosystem of health professionals. The best care we can give them is holistic and patient-centered care rather than costly and episodic. The primary-care physician plays a crucial role as the center of this ecosystem, advocating for the patient's health and coordinating all of the right resources to get them the care they need.
Robert Grossman, MD, MBA, chief medical officer at Transcend, is a board-certified physician in internal and critical care medicine. Dr. Grossman obtained his medical degree from New York Medical College, his master's degree in business administration from the University of North Carolina, and his Bachelor of Science degreein psychology from Hamilton College. He can be reached at firstname.lastname@example.org