The New England Journal of Medicine's Catalyst blog has been doing a really strong job recently -- and their post on value-based care captures the challenging, difficult, and opportunity-filled place we're at in medicine, right now.
If, as a healthcare provider, you've ever felt like the definition of "value," and how your organization pursues it, is a moving target... or if you've wondered what direction the whole reimbursement system is moving in... then this piece may have some fascinating insights for you, especially as we start 2019.
There has been a remarkable change in how reimbursement happens, even in the last couple of years. Now, a full 25% of healthcare is based on value-based reimbursement, as reported in JAMA (with the other 75% remaining fee-for-service.)
As you're likely aware, this value-based reimbursement is done in two ways:
- 1. Capitated Payments. Accountable Care Organizations ACOs use capitated payments (“subscription” per covered life per month)
- 2. Bundled payments. One payment, based on the patient's condition, which is split up among whatever services or providers treated that condition.
The mechanics of value-based payment models aren't complicated. But the perceptions of these models, the differing levels of support, and our diverse abilities to meet the models' challenges, all vary dramatically. So JAMA's New Marketplaces Insight Report, exploring the understanding and thoughts of different players in the healthcare system around these shifts, is fascinating.
First and foremost, the report suggests deep ambivalence: "Nearly half (46%) of respondents — who are clinical leaders, clinicians, and executives at U.S.-based organizations that deliver health care — say value-based contracts significantly improve the quality of care, and another 42% say value-based contracts significantly lower the cost of care." In other words, half of us believe value-based contracts are great for quality and half of us believe that they're very bad for quality. Perhaps not surprisingly, healthcare providers tend to be more skeptical about the model than executives and administrators.
Also, many, across organizations and despite their roles, don't know their organization's stance on value-based care. The authors indicate that respondent answers may show a lack of consensus on what value-based care really means. "While there is broad agreement that value in health care is represented by the balance between the patient-centered outcomes of care achieved with the costs to reach those outcomes, many individuals do not completely understand that concept." For instance, one clinician asserts that "value" isn't really a term that is useful or has a broadly understood meaning: "Right now, [value is] a convenient term that means whatever the speaker wants it to mean.”
Payers and providers are not aligned. And the high rate of salaried employment by healthcare systems adds to the confusion. Many clinicians tend to have the starting point that, "I am morally obligated to my patient, but there is no real contract between the patient and myself."
Regardless of current perceptions, there also remain practical barriers to full adoption of value-based care models. The primary barriers to the proliferation of value-based models are primarily related to infrastructure, including Information Technology. But regulatory issues, data integration, patient engagement, and others all play a role.
Of course, many of these barriers can be addressed by new tools, like iClickCare. But adoption is an interesting challenge when so many providers are ambivalent about whether value-based care is the right direction... or even how their organization is currently reimbursed.
To me, these shifts emphasize the crucial importance of healthcare collaboration. Wherever you or your organization falls regarding reimbursement, healthcare collaboration has become increasingly critical for doing the care coordination and achieving the outcomes that reimbursement shifts demand. I thought that an executive at a large nonprofit hospital in the South articulated the challenge -- and the opportunity -- of healthcare collaboration well:
"Physicians had been taught for decades that they were the final arbiter of everything that happens to their patient. When, and until, we change the culture to one of team-based care where the patient belongs to the team, we will continue to struggle with adopting value-based care. As an example, a physician with a length of stay that is 10 days longer than his peer average once told me that the hospital has a length of stay problem because the hospital gets paid a single fee for the entirety of care.”
Clinicians are decreasingly able to bury their heads in the sand when it comes to the big picture of reimbursement. But rising to the challenge of what's to come in healthcare doesn't have to be complicated. Simply working effectively with your colleagues to provide the best, most coordinated, most efficient care possible will ultimately be the best approach -- now, and in the future.
To learn more about how telemedicine can support value-based payment models, download our free Quick Guide: