As value-based care (VBC) payment models expand beyond primary care, it is crucial to accurately identify and categorize potentially avoidable utilization despite coding obfuscation (intentional and unintentional). VBC models transfer financial risk to the medical practice while purporting increased clinician decision-making autonomy. Inherent in this shift is the requirement for practice leaders to embrace cost accounting best practices with an outcomes-oriented approach. One opportunity to optimize cost accounting methodology is in complex ambulatory subspecialty care. By properly categorizing the obfuscated costs of specialty services, medical groups can more accurately capture the true cost of care and uncover areas of low value or avoidable utilization. Conventional cost accounting, designed for fee-for-service (FFS) billing, separates costs by service line and often leads to suboptimal cost containment and disrupted clinical workflows. Leveraging robust claims analytics, we use gastroenterology as an example of how to categorize cost by episodes of the patient care journey, accounting for clinician behavior, which reveals appropriate targets for interventions to reduce cost and improve outcomes. This session will review data from 50 million commercially insured patients to compare traditional cost accounting to a more patient-centered approach.
Learning Objectives:
Examine claims data for shifting cost accounting methodology from a service line to an episode of care-based model to uncover previously obfuscated and potentially avoidable utilization
Outline a framework for identifying opportunities and interventions for reducing avoidable costs depending on phase of care (diagnosis, treatment, maintenance, relapse)
Analyze potential pitfalls and gaps that remain with an episode-based approach to cost accounting and how to proactively address these gaps in discussions with health plans and employers
.jpg "Chris Harrop photo")
