Ready or not, value-based care (VBC) is here.
For providers and medical practices, the stakes are high. Despite spending more money per person on healthcare than any country in the world, patients in the United States experience the worst outcomes overall of any high-income nation.
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The problem? The traditional fee-for-service model has created a misalignment between financial incentives and desired outcomes by compensating clinicians for each service delivered, encouraging greater volume rather than improved health outcomes.
VBC seeks to restore that alignment, rewarding practices and providers for delivering measurable health outcomes and cost-effective care. Moreover, practices that embrace VBC can open significant opportunities to improve the health outcomes of their patients while preserving their practice’s profit margins under a stagnating fee-for-service landscape for reimbursement rates and increasing medical inflation. According to CMS.gov data, physician and clinical services expenditures sat at 5.6% in 2021, down 1% from 2020, while spending on VBC has grown 15% annually.
Yet embracing and adopting VBC is easier said than done.
Barriers to entry include ever-changing regulations and alternative payment models, lack of resources, unpredictable revenue streams, and a lack of access to critical healthcare data. Moreover, a practice will have to continue to support fee-for-service while participating in VBC programs. For example, a practice may support many patients in a fee-for-service model while participating in the CMS Merit-Based Incentive Payment System (MIPS) and run a Chronic Care Management (CCM) program simultaneously. As a result, organizations are faced with the daunting task of identifying and developing the capabilities required to succeed under an evolving mix of payment models.
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As reimbursement momentum shifts to VBC, practices can establish a foundational set of capabilities to drive performance across the entire spectrum of value-based care programs. These five foundational capabilities will enable practices to embrace and succeed in VBC.
- Care coordination – The ability to build patient care plans, enroll patients, and ensure patient adherence to the care plans. A chart-integrated, patient-centric care plan provides easy care team access, enables point-of-care action, and facilitates effective care coordination for patients.
- Care delivery – The ability to make care decisions based on a longitudinal view of the patient incorporating relevant care datapoints, close gaps in care, and manage referrals. Bringing care and risk gap information to the point of care, allowing clinicians to accurately diagnose patients, deliver appropriate care, and return information back to payers without disruption enables this.
- Patient engagement – The ability to engage patients during care programs with multi-channel outreach and drive desired behavior change. Practices can engage patients through multi-channel (e.g., SMS, e-mail, phone) outreach campaigns such as appointment reminders, bill payment and health-related messages.
- Performance tracking – The ability to measure performance in value-based care contracts and programs and measure the success of efforts and interventions. Real-time insight into performance can allow practices to better track progress, intervene when necessary, and more confidently predict expected results.
- Patient segmentation – The ability to define a population with a set of specific care gaps, high utilization, and/or relevant conditions, and attribute patients to clinicians responsible for their care. Leveraging tools to predict and identify patients requiring intervention can help accomplish this.
Apprehension among practices and providers is understandable, given the complexity and variance of VBC contracts. However, instead of feeling overwhelmed and burdened by VBC, practices can slowly embrace these concepts by leveraging the many tools they already have in place or that exist in the healthcare ecosystem. At the end of the day, VBC is about improving patient outcomes and the patient experience. By developing and honing these five competencies, practices can optimize financial performance under an evolving mix of fee-for-service and VBC contracts with the goal of improving patient outcomes.
Photo: atibodyphoto, Getty Images
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