The healthcare industry is moving away from traditional fee-for-service models and towards value-based care, which means that providers are increasingly being reimbursed based on the quality of care they provide, rather than the quantity of services rendered. This shift is being driven by a number of factors, including the rising cost of healthcare, the growing focus on preventive care, and the increasing use of data and analytics to measure and improve quality.
Value-based payment models have been shown to improve patient outcomes and contain costs, making them a key part of the future of healthcare. As value-based reimbursem*nt models become more prevalent, it is important for healthcare providers to understand how these value-based programs work and what they can do to ensure that they are providing high-quality, cost-effective care.
What is Value-Based Care?
Value-based healthcare is a system in which providers are reimbursed based on the quality of care they provide, rather than the quantity of care. This type of care is intended to improve patient outcomes and reduce costs. In order to be successful, value-based healthcare requires coordination between all members of the care team, including doctors, nurses, and other support staff.
The goal of value-based healthcare is to provide the best possible care for patients while also reducing costs. To do this, providers must focus on delivering high-quality care that leads to positive outcomes. Providers who are able to successfully coordinate care and deliver quality care will be rewarded with higher reimbursem*nt rates.
Value-based healthcare is a new way of thinking about how to deliver care. It is based on the idea that quality care should be the primary focus, rather than quantity of care. This type of care is still in the early stages of development, but it has the potential to transform the healthcare system by improving patient outcomes and reducing costs.
Why Value-Based Care Matters
Bettering patient health outcomes relative to the cost of care is the goal of most stakeholders across the healthcare system, including patients, providers, health plans, and government agencies. By concentrating efforts on the outcomes that matter most to patients, value-based programs can align care with positive and coordinated patient experiences. Value-based healthcare connects clinicians to their main purpose, to help people feel better, and can be an effective strategy to counter clinician burnout. Value-based care focuses on better health outcomes and aligns clinicians with their patients. When value-based reimbursem*nt works as intended, physicians spend more time on wellness and less time on paperwork.
Better outcomes decrease the need for ongoing care and reduce spending. By improving health outcomes, value-based payment models can help reduce the chances of disease progression that drive the urgency for more care. As an example, the value-based reimbursem*nt CMS is striving for would result in less diabetics progressing to kidney failure or neuropathy over time. Reducing co-morbidities is always less expensive than managing a patient with a condition that continually worsens.
Population health improves when the health outcomes of many individuals improve, which is the focus of value-based healthcare, sometimes referred to as CMS pay for performance or value-based care CMS. Costs quickly accumulate from the care provided for individuals, so organizing teams to care for individuals with similar needs enables efficiency, rather than rationing, to drive costs down. The CMS value-based care approach puts decisions about how to deliver care in the hands of the clinical team to deliver effective and appropriate value-based care.
Implementing Value-Based Programs
The adoption of value-based healthcare is altering the way physicians and hospitals provide people with care. New value-based programs stress a team-oriented, network approach to patient care management that involves the responsible sharing of patient data, so that care is coordinated. In value-based healthcare models, primary, acute care and specialty care are united in a coordinated group approach, led by a patient’s primary physician, who directs the patient’s care team.
The transformation to value-based care starts when an organization identifies and understands a segment of patients whose health creates a consistent set of needs. Then an integrated team of multi-discipline caregivers designs and delivers comprehensive solutions to those needs. This integrated team measures health outcomes of its care for each patient and the cost of services. Specialized software with artificial intelligence in healthcare like natural language processing (NLP) and machine learning can support value-based care by prospectively discovering disease suspects based on data found in the physician's electronic health record (EHR). Finally, as health outcomes improve, evidence of better care creates opportunities for more accurate value-based reimbursem*nt and the development of better value-based payment models.For a provider to receive a value-based reimbursem*nt CMS promotes patients, doctors, hospitals, and other providers to work together to deliver the best possible care at the lowest cost. This CMS pay for performance approach policy differs from the traditional fee-for-service approach, in which individual providers may benefit by increasing the quantity of health care services, regardless of whether the patient outcomes were good or bad. In the best value-based care models clinical news and insurance claims data are shared between payers and providers. Data sharing in a CMS pay for performance approach improves critical population health metrics, such as hospital readmissions, patient engagement and spending on unnecessary services, allowing for accurate value-based reimbursem*nt CMS can reimburse well for.
To be efficient, value-based programs should be structured around patient segments that share the same set of health needs, such as people with back pain or people with chronic conditions. Organizing CMS pay for performance care in this way allows clinical teams to anticipate patient needs and provide needed services effectively. The efficiency by structuring CMS value-based care around patient segments releases clinicians from scrambling to coordinate routinely needed services. The added bandwidth frees them to personalize value-based programs for individual patients who have varying needs.
The Benefits of Value-Based Healthcare
What is value-based care good for if the benefits don’t extend to patients, providers, payers, suppliers, and society as a whole? Quality and patient engagement measures improve when the focus is on value-based reimbursem*nt instead of volume-based payment models. The system rewards providers, who produce higher value per episode of care, and they can be compensated fairly under value-based payment models. Payers can control costs and reduce risk by spreading it across a larger patient population. A healthier population with fewer claims results in less impact on payer premiums. CMS pay for performance also allows payers to increase efficiency by binding payments that cover the patient’s full care cycle, or chronic conditions, or for covering periods over one year.
CMS value-based care has the promise to reduce overall healthcare costs by significantly reducing money spent helping people manage chronic diseases, costly hospitalizations and medical emergencies. Society as a whole becomes healthier while at the same time reducing healthcare spending.
Value-Based Reimbursem*nt
With the change from traditional fee-for-service to value-based care CMS has concluded that long-term healthcare costs will begin to lower, while helping patients learn to lead healthier and more productive lives. As the healthcare landscape continues to evolve and the adoption of CMS value-based care models increase, providers need to become better managers of populations of patients.
To assist in the transition to value-based payment models, and better manage patient populations, many physicians, coders and healthcare organizations are choosing to integrate specialized patient-centered software systems into their EHRs to help search and capture all the appropriate conditions of each patient in their population. Some top HCC risk adjustment coding platforms can synthesize the medical record media and quickly associate evidence for improved coding accuracy before the claim is even sent. Only with accurate, evidence based documentation of disease and chronic conditions can fair value-based care CMS reimbursem*nts be allocated to providers.
For healthcare organizations looking to succeed in the transformation to CMS value-based care delivery models, including the Medicare Advantage Program, ForeSee Medical is a specialized software platform for accurate Medicare risk adjustment. Through artificial intelligence like proprietary medical algorithms and natural language processing, ForeSee Medical optimizes HCC coding, empowering providers to positively influence health outcomes.
SEE HOW IT WORKS
