Value Based Care & Reimbursement

Value Based Care Models

“America’s health-care system is neither healthy, caring, nor a system.”

Since Walter Cronkite first said it in 2013, the US healthcare system has continued to struggle to meet this most basic definition and the goals of delivering better health (life expectancy is decreasing) and better outcomes (chronic disease prevalence is increasing) at a reasonable cost (highest in the world by a multiple). Value-based care and emerging reimbursement models are targeted at fixing this challenge by rewarding providers that deliver on all three challenges. Though we’re not there yet, it’s estimated that by 2020, 80% of payments will be value-based. Additional risk and gain-sharing models will make value the primary driver of reimbursement from that point forward.


There are a number of elements as part of value-based care models that have the potential to deliver on the title; they include incentives alignment, patient centered medical homes, patient engagement/convenience, chronic care management, care transition support and more. The new reimbursement models to drive this change include MACRA, bundled payments, ACOs, gain-sharing and others

A critical enabler for these components ability to succeed is data analytics and augmented intelligence.

Effectively utilizing and managing information from various sources will be key to this transformation. Additional primary considerations include:

  • Stakeholder alignment
  • Patient centricity and related tools
  • Enabling evidence-based medicine/augmented clinical decision-making
  • Clinical practice culture
  • Chronic care support and managing care transitions
  • Improvement cycles and change management

Aligning Incentives with Results

Alignment is key – and lack of it is the best excuse healthcare has for the slow focus on value.  Without aligned incentives built into value-based models, the care approach will not evolve.  Alignment is increasingly being implemented in physician payment schemes and bundled payment approaches; which is a step in the right direction but can be expected to continue evolving as the transition continues.

Consumers vs. Patients

Two key elements here include:

  1. 1. Dramatic improvements in convenience factors for consumers and meeting them where they want to be met for care
  2. 2. Actively engaging consumers in their care

Giving consumers more options and treating them like consumers versus patients is a key transition for healthcare and is playing out in an accelerated way; convenient clinics, telemedicine, even house calls will be part of the evolution. Engaging consumers both as partners in keeping themselves healthy and as a loyalty factor for the provider will be enabled by a number of technologies including remote monitoring, IoT and even BOTS that drive cost effective interaction. New care models focusing on education and coaching versus compliance and adherence are a critical and fundamental shift.

Follow the Facts

Smart data and the ability to rapidly digest medical research are key enablers to make dramatic improvements in the quality and consistency of care. The volume of data on care and outcomes will set “evidence bases” in areas which were previously too complex to assess and inform/measure when the evidence base is not followed. The ability to gather a 360 view of the patient and process against all available medical research will augment diagnosis and treatment options – at a speed that will be viable in clinical workflows.

It Takes a Team

A combination of new reimbursement models and maturing tools/aids will drive a transformation of medical practice from single threading through physicians to enabling a care team to support the needs of the consumer—and it will be more cost effective. Augmented intelligence will up-skill everyone in the practice from the physician to the community health worker. Providers that invest in the tools and adapt faster will be the winners in value-based models.

Keeping an Eye on Chronic Care

Keeping consumers with multiple chronic conditions healthy and out of expensive care settings will be a key driver in value-based models. Support for chronic care and transitions will evolve from what today are personnel intensive and expensive processes into information intensive and alert-based approaches. The new data-enabled approaches will leverage more data points and engage consumers for more data gathering and nudges, only bringing in professional care-givers when needed. Monitoring patients through transitions will make sure no balls are dropped and the right parties stay engaged.

Prioritizing Change Management

The transformation to a value-based care model is going to require an evolution (versus a revolution) as payment models shift, capabilities and tools are put in place and become standards of care, and medical professionals adapt to the new order – or stop practicing. The shift is accelerating and will need to be managed through improvement systems with a heavy focus on change management and process and outcome measures to make sure the cycles are sticking.

Your Partner in the Volume-to-Value Shift

Value-based care models of various shapes and forms are coming – from MACRA to bundled payments to ACOs to various gain sharing and incentives. The areas and priorities will be different for payors and providers based on their lever points, strategic relationships and the speed of a geography’s fee for value transition. Some key enablers and tools critical to supporting value-based care models will include:  Advanced Analytics, Streaming Data & IoT Solutions, AI & Machine Learning and significant Change Management strategies to pivot existing models.

Amitech involvement with early efforts to help the industry manage this transition has helped us to develop considerable expertise around the necessary collaboration and data applications for success. If you’re interested in discussing how we might be able to leverage our experience to help your practice or organization navigate the shift from volume-to-value, please contact us.

 

Featured Content

White Paper: Making Sense of MACRA

Your Guide to Understanding the Shift to Value Based Care & the Data Infrastructure Needed to Support Provider Success

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