If the healthcare industry has learned anything from the Centers for Medicare and Medicaid Services' (CMS) experiments with managed and value-based care, it all boils down to one thing: Expect more. Efforts to align payments and provide high-quality care at the best possible price won't slow down any time soon.
Value-based care models hold huge promise and represent the best chance for CMS to do away with the inefficiencies of a fee-for-service system that has often incentivized the wrong kind of care. But the new and experimental nature of these programs, combined with the huge challenges they present around care redesign, means healthcare executives often find themselves creating programs from a blank slate. That proverbial fresh page presents a tremendous opportunity for care redesign, but also comes with the risk of broad financial responsibility for patient outcomes that providers assume under value-based models.
Executives who take part in redesigning workflows and roles around value-based care will need to make decisions about IT, patient tracking, care management approaches and interdisciplinary integration to prepare for the rise of value-based care models. They should select and design them for scalability, flexibility, effectiveness and efficiency.
Data analytics
The inability to store and analyze data on patients' use of healthcare services impedes a medical provider's ability to manage care and costs. Large practices and hospitals can generate this data by mining their own claims. But they'll need robust and actionable systems to analyze it and identify patterns that generate outsize spending. That evaluation should focus priorities to drive care redesign while directing resources to build on existing successes.
The best opportunities for improvement will vary among markets since practice patterns, the supply of services (e.g., number of hospital beds, number of post-acute provider types) and certain patient characteristics vary. There's no one-size-fits-all solution. Care redesign teams must invest in focus areas most critical to achieve better outcomes and lower spending for their region and patient population. Being able to effectively identify and monitor the impact of these investments, while continuing to develop these initiatives, requires robust use of data analytics.
Patient engagement
Depending on the type of value-based payment model, patient engagement initiatives should be defined around two key periods of time.
The first is upon discharge following an inpatient hospitalization, whether that involves a transition to a post-acute setting or the return home. These transitions are the best times to meet with and educate patients. The other key time period is when patients are being monitored or managed by their primary care doctor to actively prevent readmission following a hospitalization or to actively manage a chronic condition.
These time periods are important because under value-based payment models, hospitals and practices may take broad financial responsibility for a patient's care. How long they remain responsible depends on the model, but the difficulty is that patients may fall out of a care facility's immediate control during the allotted period. Executives must configure care teams so case managers, care navigators and physicians can actively coordinate their responsibilities to educate patients, engage caregivers and coordinate transitions of care to ensure discharge instructions are followed.
Since the patient plays a critical role in this process, some Accountable Care Organizations (ACOs) administer the Patient Activation Measure (PAM) in order to assess patients' ability and willingness to play an active role in the management of their care. Effective patient engagement approaches assist in better managing chronic conditions and can reduce the incidence of avoidable readmissions.
Longitudinal care management
Approximately 40 percent of Medicare beneficiaries are discharged to a post-acute care (PAC) setting such as a long-term acute care hospital, inpatient rehabilitation facility, skilled nursing facility or home health agency following a hospitalization. In one review of Medicare claims, about 52 percent of patients discharged into PAC are treated in more than one post-acute facility before transitioning home.
The financial incentives of value-based care dictate that hospitals approach care management longitudinally, with an eye toward the management and monitoring of patients over time and in multiple settings. That's why it's critical to work closely with a defined network of PAC providers that are committed to achieving the quality and financial goals under the value-based care arrangements of the hospital.
Patients with multiple chronic conditions likely will use a variety of healthcare services and settings throughout the year. Hospitals will need the ability to track and monitor patients across the delivery system, creating an individualized care plan that addresses evolving care needs. The capacity to communicate with healthcare providers across the care continuum is vital to the success of a value-based care model.
Even if patients aren't actively receiving services, healthcare facilities should develop programs and technology that allow them to remotely monitor and assist patients managing chronic conditions at home, which prevents unnecessary emergency department and hospital utilization. Under the new chronic care management (CCM) codes billable under Medicare, physician practices are designing approaches to conduct monthly non-face-to-face interactions such as phone calls, emails and telehealth initiatives to monitor patients.
Interdisciplinary care
Under value-based care, non-medical factors are often equally as important as traditional therapies, but are often beyond the influence of doctors and case managers. Behavioral health-related issues, for example, have been proven to significantly increase healthcare spending, particularly when combined with active medical or chronic conditions.
Hospital executives should seek outside resources or partnerships that can adequately address patients' behavioral health needs, as well as nutrition, financial, transportation and other socioeconomic issues that affect health. Processes then must be implemented to connect patients to community resources that can address these factors that may impede their ability to follow self-care instructions.
Many ACOs are adding behavioral health assessments, like Patient Health Questionnaires (PHQs) including PHQ-2 or PHQ-9, into their standard intake process and even embedding behavioral health clinicians into high-volume physician practices.
Bringing it all together
While these capabilities may seem daunting to many executives, it's important to note that no single person, be they doctors, nurses or social workers, has the time or skills to perform all of these functions. Therefore, it's imperative that new roles are established within organizations to develop and manage these capabilities. That may mean outsourcing data analytics, hiring a local, well-connected case manager and/or health coach or strengthening a network of community partners.
Analytics, care design and patient tracking capabilities feed into and reinforce one another. A competency in one area will improve the quality of another. Conversely, it is unlikely that excelling in one of these areas alone is enough to make a sustainable transition to value-based care. The transition from fee-for-service models into an ACO requires careful planning and review of care design, but it can provide an excellent opportunity to drive improvements in patient care while cutting costs.
About the author:
Brian Fuller is the Vice President of Value-Based Care at naviHealth (www.navihealth.us), and an expert on the impact of post-acute care in new healthcare reform environments and care integration and partnership development across the continuum.
The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.