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Value-Based Healthcare Framework

Change doesn’t come easy in an industry as complex and regulated as healthcare. It requires a thoughtful strategy and a stepwise path that accrues benefits along the way. Download the one pager to discover a framework that can help you prioritize value in your healthcare partnerships.

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A Shift from Volume to Value

Across the healthcare industry, there has been a shift from volume to value, where healthcare suppliers, providers, systems, employers, and payers are aligning their economic interests to work together on the improvement of patient care.

Navigating a Complex Industry

The challenge is that even with collective commitment to positive patient outcomes, it can be difficult for partnering healthcare organizations to align on a shared expectation of value or track value delivery over time. That’s where MetaCX can help.


Healthcare Assets

Value-Based Healthcare Framework

The shift from a fee-for-service healthcare delivery model to a value-based care model has significantly changed the way healthcare is administered and reimbursed across the United States healthcare industry.  Priding itself with being able to provide the best healthcare in the world, the US has been making a shift toward a value-based healthcare framework. But what does that really mean?

Value-Based Care (VBC) is a healthcare model that is based on the quality and continuity of care rather than quantity of services rendered. Continuity of care means healthcare suppliers, providers, systems, and payers take accountability in continually fostering positive outcomes in patients.

The traditional fee-for-service model is based on volume (for instance, the number of tests run or services provided) while VBC is based solely on overall patient outcomes

What Is Value-Based Healthcare

Transforming how healthcare providers are reimbursed for services rendered, the Centers for Medicare & Medicaid Services (CMS) has introduced an array of value-based care models, such as the Medicare Shared Savings Program and Pioneer Accountable Care Organization (ACO) Model. Private organizations have in turn adopted elements of value-based care framework.

Why implement value-based care in a healthcare organization? Improving a patient’s health outcome in relation to the cost of care is an aspiration embraced by stakeholders across the healthcare ecosystem, including healthcare suppliers, providers, systems, payers, and the patients themselves.  By focusing on the outcomes that matter most to patients, population health is improved, costs are reduced, and operations are made more effective. Certain elements of value-based healthcare lead to lower readmission rates, more effective treatment, and equality in care across all social and economic groups.

VBC is perceived as the strategy that will fix healthcare by connecting clinicians to their purpose as healers, supporting their professionalism, and becoming a powerful mechanism to counter clinician burnout. As a testament to its positive impact, VBC isn’t a concept restricted to the US. Many countries are making the shift. For instance, England is currently in the process of adopting value-based healthcare NHS (National Healthcare System).

Value-Based Healthcare Vs Fee For Service

With fee-for-service healthcare, doctors are paid a fixed amount no matter what happens to the patients whereas value-based reimbursement models compensate providers not for the number of procedures performed, but rather for the quality of the care they provide, measured by patient health outcomes. In a value-based reimbursement model, providers are rewarded for effectively managing the health of individuals and populations.

Fee-for-Service vs Value-Based Care Scholarly Articles

According to an article from the Health Affairs journal, the National Commission of Physician Payment Reform recommended in 2013 that payers “largely eliminate stand-alone fee-for-service payment to medical practices.”

Conversely, an article from the Research in Social and Administrative Pharmacy journal states that public and commercial health plans are transitioning from fee-for-service payments to value-based payments.

History of Value-Based Care

In 2008, CMS initiated the Medicare Improvements for Patients and Providers Act (MIPPA) which, in part, rewarded eligible healthcare providers for electronic prescriptions. The next year, the Health Information Technology for Economic and Clinical Health Act (HITECH) was included in the American Recovery and Reinvestment Act of 2009 (ARRA). HITECH established programs under Medicare and Medicaid to provide incentive payments to eligible healthcare providers for the “meaningful use” of certified electronic health record technology.

The Affordable Care Act (ACA) was implemented in 2010. ACA placed more emphasis on quality care and authorized several value-based programs that rewarded healthcare providers based on that quality rather than on quantity. Just a few years later, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was signed into law as bipartisan legislation on April 16, 2015.

Examples of Value-Based Care

What does the healthcare industry’s commitment to value look like in real life? Some examples of value-based care initiatives include:

Patient-Centered Medical Homes

The patient-centered medical home replaces one-off, episodic care with a sustained relationship between patient and doctor.

Accountable Care Organizations

In accountable care models (ACOs), insurance providers partner with healthcare provider organizations that agree to be held responsible for (or share in the risk of) the quality, cost, and overall care for a defined population of patients.

Bundled Payments

The use of a bundled payment involves paying providers, or a group of providers, based on defined episodes of care. This typically includes associated healthcare services under a single fee or payment.

Benefits Of Value-Based Healthcare

The comprehensive goals of value-based care include improved population health, increased patient satisfaction, and reduced costs. As the goals are very clear, the strategies to achieve value-based care aren’t always so cut and dry. Patient benefits of value-based care are the main driver of the transformation, so what matters to patients?

What matters to patients: a timely question for value-based care:

Affordability

In a value-based healthcare model, patients have fewer doctor visits, medical treatments, and medical procedures. Instead of volume, the focus is on providing value in the most efficient and effective way possible.This ultimately reduces healthcare spending while improving patient health conditions.

Increased Satisfaction

The benefits of value-based care for populations are vast, but ultimately come down to patient satisfaction. Unlike the fee-for-service healthcare model, VBC ensures that physicians are solely focused on the health of patients and don’t have  monetary motives. This usually translates to patients feeling more satisfied with their treatment.

Improved Care

Often in a traditional healthcare model, healthcare providers are not incentivized to work with partnering healthcare organizations to provide effective care to their patients. In a value-based healthcare system, there are mutual benefits and improved technologies that enable providers to coordinate care. The rationale for implementing value-based care in a healthcare organization is that it ensures healthcare suppliers, providers, systems, and payers all work together to improve patient care as a whole.

Value-Based Healthcare Challenges

While the value-based care model is growing in popularity, there are still several major challenges when transitioning to such a system. Implementing value-based healthcare in an industry that is so regulated and complex can present barriers to healthcare suppliers, providers, systems, payers, and patients alike.

For one, tracking the creation and delivery of value in healthcare is a challenge. Value-based care metrics are almost impossible to come by because they require independent healthcare entities to share data with one another. You’d think that would be easy considering that the healthcare system is abundant with data created and captured throughout the patient journey, but that’s not the case. The problem is not due to an absence of data but rather a lack of trust that leads to ineffective data sharing between healthcare partners. All value-based care peer-reviewed articles will tell you the same thing.

Furthermore, the value-based care market size is only growing, which can make it difficult to ensure alignment between partnering healthcare organizations. In order to transition to value-based care, everyone has to be on the same page and working toward the prioritization of positive patient outcomes.

Value-Based Care Model

All value-based reimbursement models in healthcare emphasize quality over quantity of services provided. The terms “value-based care” or “value-based payment” include all types of value-based care models and payment models including alternative payment model (APM), advanced APM, bundled payments for episodes of care, pay for performance, shared savings programs, and “full” or “capitated” payments. APMs can apply to a specific clinical condition, a care episode, or a population.

In 2006, Michael Porter published the book Redefining Health Care: Creating Value-Based Competition on Results. Porter describes the transformation of care to Value-Based Healthcare based on six elements. On the website of Harvard Business Review, you will find a detailed explanation of the Porter model and all six elements involved.

MetaCX offers software that optimizes the flow of value across the entire healthcare industry, connecting healthcare suppliers, providers, systems, and papers in a shared system of record for value creation.

Value-Based Care Strategies

Improving value in healthcare is not an unreachable ideal. By defining and implementing value-based healthcare: a strategic framework, various healthcare organizations (with an array of regulatory structures and many different care traditions) have demonstrated dramatically better health outcomes for patients at lower overall costs.

Strategies used to implement value-based healthcare are varied. It usually starts with a healthcare system identifying  and understanding a segment of patients whose health and related circumstances create a consistent set of needs. That leads to a dedicated, co-located, multidisciplinary team of caregivers designing and delivering a comprehensive solution to those needs. This integrated team tracks and measures meaningful health outcomes for each patient and the costs of its services and then learns from that information to drive ongoing improvements in care and efficiency.

Strategies for implementing value-based care from a nursing perspective can be very beneficial, as nurses have the most recurring contact with patients. Finally, as health outcomes improve, evidence of better care creates opportunities for the team to serve more patients through expanded partnerships.

Future Of Value-Based Care

While value-based care trends of 2021 include both successes and failures, there are some lessons about what works. The future of value-based care will continue to evolve as a result of market pressures.

Some bundled-payment programs and ACOs have proven capable of reducing costs and improving the value of care delivered. Programs that use two-sided risk (like Value-Based Agreements) seem to have the greatest impact. But successful value-based care payment transitions take time; the savings and practice transformations from APMs take years of experience and investment to pay off.

For healthcare organizations hesitant to transition to value-based healthcare, top value-based care companies may be useful shepherds.

Value-based care statistics 2021 yield important insights. For example, alternative payment models must focus on optimizing shared decision-making tools and health IT infrastructure. Generous fee-for-service payment affects the adoption of and effect of APMs, and federal efforts to reduce the draw of fee-for-service have so far been underpowered for the task.

Value-based healthcare 2021 must focus on expanding the most effective APMs that utilize two-sided risk, engaging more providers, and retaining current APM participants while graduating them to high-powered programs to be successful.

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