Value-based care is a concept that is spreading throughout the healthcare industry. Many believe it could become the industry standard. Although the healthcare industry hasn’t reached that point yet, that day may eventually arrive. In preparation, use this guide to learn all about value-based care.
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Value-based care is a medical services model in which practitioners and providers are paid based on the quality of their care. The concept is the work of the Centers for Medicare & Medicaid Services (CMS). In fact, the Department of Health & Human Services had previously aimed to convert 30% of fee-for-service Medicare claims to the value-based system. However, as of 2018, only 25.1% of all claims (Medicare or otherwise) were value-based.
As of 2018, roughly 1 in every 4 claims was value-based.
Payers reimburse physicians operating on a value-based care model different amounts of money depending on how their services encourage patient health. In this system, high-value care is defined as enabling patients to live comfortable lives and avoid chronic conditions.
Value-based care models differ substantially from traditional fee-for-service models. The primary differences between the two models are as follows.
These are some of the reasons the government and many prominent healthcare organizations have advocated for a gradual shift to value-based care:
Value-based healthcare is more than a theoretical concept. Many effective value-based models already exist. These models are explained below.
CMS developed ACOs to increase the quality of services paid for via Medicare. The idea underlying ACOs is that primary care doctors should work with outside practitioners and hospitals to coordinate high-quality, low-cost patient care at every step of the way.
The ACO arrangement incentivizes each group involved in a patient’s care to work toward a common goal: the patient’s well-being. By comparison, in fee-for-service models, each group might instead prioritize providing as many services to the patient as possible, ordering excessive tests to earn more money.
The link that connects all the disparate entities in an ACO is the patient. As such, the patient is as involved in their care as their providers are.
Data sharing is also key in ensuring the members of an ACO remain focused on the same goal. Although most data points pertain solely to one patient, they can depict a bird’s-eye view of how an entire population is faring. ACO members also share their data with payers as the evidence for claim values.
VBP, another CMS program, introduces a value-based model for acute care hospitals. VBP is perhaps the most concrete value-based model: Payers adjust their reimbursements based on the quality of care provided. This approach incentivizes acute care hospitals to avoid adverse events and act more transparently. It also encourages hospitals to prioritize patient satisfaction and engagement at all levels, resulting in better patient outcomes.
Medical homes aren’t necessarily physical structures. Instead, they’re teams of practitioners spread among several facilities who all play a role in a patient’s care. The patient’s primary care doctor will oversee all practitioners’ involvement and communicate closely with the patient. This results in a unified experience as the patient moves from doctor to doctor.
The term “medical home” is a misnomer. It represents a figurative structure within which a patient’s many providers are housed.
Medical home models are predicated on the interoperability features that come with the best medical software. These features ensure that disparate facilities can share clear, fully comprehensible patient data in HIPAA-compliant ways. They allow all of a patient’s practitioners to see key lab results or other data at a moment’s notice, preventing dips in the quality or consistency of care.
The PCMH and ACO models overlap in the way they involve the patient and provider on equal levels. The PCMH model’s heavy emphasis on data sharing resembles the ACO model as well. Both models can eliminate care redundancies and the extra money lost to them.
In some ways, bundled payments are part of all the above value-based models. However, they merit discussion on their own, since their structure may best explain value-based care’s potential to disrupt the medical industry.
Practitioners working in bundled payment models file one claim for all services provided to a patient in a given period. This bundling is the opposite of standard medical billing and coding, in which each service provider gets its own ICD-10 or CPT code. This model both introduces substantial potential for error (though claim scrubbers can help on that front) and incentivizes providers to prioritize quantity over quality. Bundled payments solve these problems.
In bundled payments, only one number matters: the value of the patient’s care experience. The number of tests, exams, diagnoses and appointments that comprise the patient’s care cycle is insignificant compared to the signifier of an excellent patient outcome. This means that an extensive set of tests and encounters that barely improves the patient’s health is less valuable than a smaller set with a highly positive outcome.
Value-based care presents a potentially radical shift in how medical services are provided and paid for. As steps toward this model proceed, medical billing experts will notice how they affect longtime billing procedures. That’s why outsourcing your medical billing to a third-party company is a good idea. Consider our review of AdvancedMD, which is best for large practices, or our review of DrChrono, which is better for small practices.
With medical billing companies in your corner, you’ll never fall behind as the medical industry transitions from fee-for-service models to value-based models.