Transitioning to Medicare’s Value-Based Models within Primary Care: Business Practices for Success

The United States spends an estimated 18% of its GDP on healthcare, more than all other developed countries, but has worse outcomes than most of them. Americans agree healthcare requires reform. Primary care reform is particularly important because strong primary care systems are highly correlated with improved health outcomes and lower healthcare costs. Previously, Medicare clinicians were compensated through a volume-based model, which reimbursed clinicians based on the number of procedures or services they performed and lacked cost-control incentives. However, the Centers for Medicare & Medicaid Services (CMS) began pushing strongly towards value-based reform in 2008. In a recent effort to improve healthcare quality while lowering costs, the CMS passed legislation in 2015 that mandated participation of certain providers in their value-based payment models, Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). These models require providers to assume greater financial risk and to report patient outcomes in greater detail. Providers report a lack of guidance and a steep learning curve during the transition to a value-based system. This study analyzes the MIPS and APM models and proposes a set of guidelines for transitioning to Medicare’s value-based models. The business practices for success identified in these guidelines were obtained through a qualitative analysis of trends from value-based medical practice case studies. Primary care providers can best prepare for value-based reimbursement by coordinating and integrating with a network of hospitals and other providers, standardizing EHRs across the provider network, and generating real-time performance reports. They may also develop medical condition-specific protocols and create initiatives to boost patient and provider engagement.College of Natural Science