The age of value-based healthcare is here, and the Centers for Medicare and Medicaid Services (CMS) has taken the lead in healthcare delivery and reimbursement reform. The strategy is driven by a three-part aim to offer better quality health, to improve patient healthcare experiences, and to deliver services at lower costs. CMS has designed an array of care programs and payment models that are meant to shift the focus of healthcare from volume-based care to value-based care, to change the mindset of providers in today’s healthcare system to focus on quality over quantity. However, this change is not a “light switch” type of adjustment, where providers can simply make a small modification in their care delivery process to comply with new healthcare guidelines. Quality-over-quantity reform takes patience and time, and providers will be affected in three significant areas—compensation, collaboration, and data collection and reporting—as they transition into this new era of value-based care.
In the transition to value-based care, providers are challenged to operate in a state of payment duplicity, working in a declining, traditional fee-for-service (FFS) reimbursement model, while preparing for and participating in value-based contracts and payment models. Quality and efficiency are the goal of every value-based payment model, and CMS’s intention is to eventually transition every provider from fee-for-service to value-based care, linking provider quality performance to provider compensation. In this new strategy, an increasing amount of provider compensation is based on quality performance in areas of patient and caregiver experience, care coordination and patient safety, preventive health, and clinical care for at-risk populations.
If the value-based methodology of quality-over-quantity is embraced, healthcare providers may experience greater freedom in how they practice, and they may see significant compensation as a reward for attaining and improving quality performance over time.
There are four conceptual “templates” for value-based care, and each consists of multiple models specific to specialty, episode, and patient population:
Traditional fee-for-service reimbursements compensate providers for each service rendered, with no account for care, cost, or outcomes. Value-based reimbursements are designed to reduce costs and improve patient care and population health by financially rewarding healthcare providers for considering quality of care, cost-efficiency, and patient outcomes. For example, providers who participate in CMS’s Medicare Shared Savings Program (MSSP) must meet minimum, quality performance, threshold requirements in order to receive a percentage of net savings realized. In addition, if providers participate in an Advanced Alternative Payment Model (AAPM) they receive a 5% bonus. If the value-based methodology of quality-over-quantity is embraced, healthcare providers may experience greater freedom in how they practice, and they may see significant compensation as a reward for attaining and improving quality performance over time.
ACOs are instrumental in the long-term strategy of coordinating care to improve quality and value, and this collaborative approach is helping providers to realign their methodology to focus on value-based care rather than volume-based care.
The value-based healthcare environment is one of collaboration, a team mentality where providers are expected to work together to engage with patients, to provide care appropriate to each individual’s circumstances, and to align their efforts with multiple partner providers across the healthcare continuum. This strategic shift in quality healthcare is extremely beneficial to patient populations because it delivers a connected care experience where patients receive more coordinated, appropriate, and effective care. Healthcare providers are required to think outside of their fragmented, “siloed” approaches, and they are encouraged to work more freely within a community of providers to utilize “best practices” to offer the most appropriate and cost-efficient care for patients. Providers experience a “connected” approach to healthcare through the interoperability of health IT systems that might help to enroll patients, receive alerts on admissions, discharges, and transfers, or be used to document and share care plans across the patient’s collaborative care team, giving providers a complete view of the patient’s care at every stage of the patient’s healthcare journey.
Accountable Care Organizations (ACOs) are the premier example of collaboration within the value-based care strategy. ACOs are entity groups consisting of networks of physicians, specialists, surgeons, pharmacies, and hospitals who agree to coordinate care for a patient population, with the goal of improving quality care, while eliminating unnecessary spending. ACOs are instrumental in the long-term strategy of coordinating care to improve quality and value, and this collaborative approach is helping providers to realign their methodology to focus on value-based care rather than volume-based care.
Data collection and reporting may be the most critical facets of value-based care where providers must be fully engaged and committed. Value-based care is driven by data, and providers use this data to collaborate in the full scope of a patient’s medical experience, providing the appropriate care at the right time. In addition to collecting patient data to provide overall better-quality care, providers must collect performance data and report to CMS (and other contract payers) on specific measures to demonstrate quality attainment and improvement. For example, for years 2018 and 2019 ACOs must track and report on 31 quality measures, such as hospital readmissions, and screenings for breast cancer, clinical depression, and fall risks. In addition, ACOs must conduct patient surveys to track the timeliness of patient care, appointments, and the sharing of information. ACOs participating in the Medicare Shared Savings Program are graded on these quality performance measures, and their scores directly affect the percentage of shared savings received.
Data collection and reporting is vital, and providers must be prepared to invest in and to learn new technology to capture data and measure analytics, to evaluate processes and performance, and to share performance data involving patient care, as well as provider and peer-to-peer analysis. Providers must embrace transparency in the value-based care environment, realizing that collaboration and compensation are contingent upon the sophisticated collection and reporting of performance data.
Value-based care recognizes quality, not quantity, as the key to better care, better health, and reduced costs. For most providers the transition to value-based care will take substantial time and perseverance, but success is achievable if providers will embrace the principles behind this focused quality approach, commit to the ongoing process of learning and improving, and strive for excellence in efficiency and quality achievement.
North Texas Clinically Integrated Network, Inc. (dba TXCIN) is a non-profit ACO that began in late 2014. A small group of independent physicians aligned to initiate clinical integration and value-based contracting. Partnering with RevelationMD and its state-of-the art information platform, TXCIN has become the largest independent network of physicians in North Texas.
Belliveau, Jacqueline. “What is Value-based Care, What Does It Mean for Providers?” RevCycle Intelligence. https://revcycleintelligence.com/features/what-is-value-based-care-what-it-means-for-providers