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: 

Moody’s Investors Service came out with their 2019 projections and predictions for nonprofit hospitals.

And unfortunately the summary is: things don’t look great.

Although I don’t put tons of confidence or stock in this type of projection, I do think that the report captures many of the challenges that nonprofit hospitals face.

Fierce Healthcare does a good job summarizing Moody’s report: Moody’s says that nonprofit hospitals are on an “unsustainable path” because of “soft revenue growth, weak inpatient volumes and single-digit reimbursement increases in the coming year.”

Other challenges in 2019 may include lower cashflow, an increase in bad debt, lower inpatient admissions, and pressures like nursing shortages and increasing wages.

So much of healthcare is conservative. We don’t change until we need to. And for many nonprofit hospitals, there has been a consistent tendency to maintain the status quo in an almost superstitious fashion — if I don’t change, then nothing will change around me.

Reports like this demonstrate that things are surely changing around us. Our only choice as healthcare providers, as hospital administrators, and as citizens is whether and how to act proactively so that the things that matter to our organizations and to ourselves can be supported and pursued.

Healthcare is changing around us -- for better and for worse. 2019 will bring new technologies, shifts in reimbursement, demographic changes, and developments in our own practice as healthcare providers. Our goal can't be to not change within that. Our goal has to be to change towards what we envision for ourselves and for our patients. And with the new year here already, I encourage all of us to take the opportunity to reflect on what that might look like this year.

 

Medicare is a crucial part of our healthcare system. Although some providers feel themselves unwilling or unable to accept Medicare, the reality is that 44 million people are beneficiaries. It impacts those people, as well as our healthcare system as a whole. This is important because the whole healthcare system tends to lean towards Medicare's policies.

So a new proposed rule affecting telehealth is practical, crucial, and fascinating to explore. 

Just recently, Medicare announced a new proposed rule for public comment and review that would greatly expand payment for telehealth. 

The full proposed rule change can be found here, but the general shift leans heavily on Medicare Advantage plans and is summarized as follows: "Under this proposal, MA plans would be permitted to offer – as part of the basic benefit package – additional telehealth benefits beyond what is currently allowable under the original Medicare telehealth benefit. In addition, we propose to continue authority for MA plans to offer supplemental benefits (that is, benefits not covered by original Medicare) via remote access technologies and/or telemonitoring for those services that do not meet the requirements for additional telehealth benefits."

The explanation and rationale for the shift includes this insight: "The healthcare industry has made significant advances in technology that enable secure, reliable, real-time, interactive communication and data transfer that were not possible in the past. Moreover, the use of telehealth as a care delivery option for MA enrollees may improve access and timeliness of needed care, increase convenience for patients, increase communication between providers and patients, enhance care coordination, improve quality, and reduce costs related to in-person care."

Not only is this a powerful positive development for medicare beneficiaries as well as healthcare providers who use telehealth -- we believe this represents an important philosophical shift. Telehealth is not an "an additional benefit" -- it's one of the many tools that healthcare providers have at their disposal to provide excellent care to all patients. This proposed rule is an important step away from that "special benefit" status of telehealth -- and towards it being just one more tool in our toolbox. 

Further, it is recognized that significant savings can come from the use of telehealth, as well as increased access by people who may be in rural, underserved, or hard-to-reach areas.  

The commonsense of telehealth seems to be slowly eroding the granite barrier of Medicare’s policy toward payment for telehealth.  As you know, there are significant restrictions about who, where and how a patient could benefit from technology applied to day-to-day care. Currently, live video conferencing from specific sites is the only reimbursable use of telehealth for Medicare recipients. We, of course, are strong believers in using technology to shift time as well as shift place. Hybrid Store-and-Forward Telemedicine®, for instance, uses asynchronous collaboration -- you respond on your own schedule -- so that both the patient and provider can solve problems without always using expensive hardware and having the interruption of scheduled appointments.

We understand CMS’s concerns about the potential for fraud and agree with the concerns. However, in our modern society with a fragmented health care system, collaborative and coordinated care has benefits that outweigh the risks.

For providers who care about good medicine and thoughtful healthcare, this new rule is an important development -- and likely shows the direction that reimbursement and medicine in general is headed. 

 

To learn more about Hybrid Store-and-Forward Telemedicine, including reimbursement issues, download our white paper: 

 

Telemedicine is a technology with almost unlimited applications — most of which healthcare hasn’t even thought of yet.

Currently, however, telemedicine is primarily applied in pretty narrow ways. Commonly, telemedicine is used for provider-to-provider communication within the usual structure of visits. Or, it is used to allow far-flung patients to approximate a usual visit, but at a distance.

A new study turns a lot of this on its head, bringing into question our ideas about where healthcare need take place, and under what conditions.

A recent study, published in the New England Journal of Medicine, looked at the ways that it’s not just the treatment or the information that matter — it’s also where that treatment comes from, and from whom. In the study, a cluster-randomized trial, black men got blood pressure intervention in two different ways. The control group had their blood pressure measured in a barber shop, but were then referred to a physician for management. The intervention group received treatment in the barbershop itself.

More than 63 percent of the intervention group achieved a normal blood pressure level after 6 months, compared with less than 12 percent of the control group.

Dr. Aaron E. Carroll wrote a great piece on the study in the New York Times recently. As he summarizes, “Health care need not take place in a doctor’s office — or be provided by a physician — to be effective.”

In fact, Carroll argues that this approach was dramatically more effective than it would have been had it been a more traditional, hospital-centered approach. He identifies a few key factors that made this intervention such a success. The care was: 

• From a trusted source.
• Low inconvenience.
• Integrated with peer support.

Dr. Carroll does point out that there are reasons that this kind of approach isn't common, however. “Health care reimbursement in the United States usually focuses on the clinical encounter, at a physician office or hospital. This reflects a belief that care is best offered there, even when evidence says otherwise. Coverage and payment focus on the individual patient, not on the community, even when research shows that the latter is more effective.”

This analysis really resonated with us as well. Telemedicine has the profound potential to support care that is from a trusted source, low inconvenience, and integrated with peer support. It has the potential to enable care that is deeply embedded into the communities, culture, and lives of the patients we serve, allowing the most advanced care, but in nontraditional settings, and with nontraditional providers as core parts of the care. Because ultimately, we don't have a failure of technology to support it -- we have a failure of imagination for what these initiatives can look like. And, as Dr. Carroll says, we have a failure of the reimbursement and payment systems. 

This powerful study is proof positive, though, that we don't have to wait for the whole healthcare system to change in order for brilliant things to happen. A simple initiative, caring participants, and thoughtful, respectful design -- these are the things that enable change to happen.

 

In recent weeks, we had some good news for those providers using telemedicine to collaborate and care for their patients.

The Centers for Medicare and Medicaid Services (CMS) approved several requests by the American Telemedicine Association to expand healthcare services that are eligible for reimbursement. In the agency’s proposed Medicare rulemaking for 2015, coverage has been expanded to include:

• More psychotherapy allowances
• Prolonged serves in the office
• Annual wellness visits
• Remote testing
• Non-face-to-face chronic care services.

This is part of an overall trend: in fact, Medicaid coverage of telemedicine has increased in 20 states and 21states now mandate private insurance coverage. The new CMS proposals are slated to go into effect January 1, 2015 and the notice can be found here.

 

And for our Quick Guide to one of the most reimburseable forms of telemedicine, click here: