Laura Dorr

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The transition to value-based care models from the traditional fee-for-service systems that prioritize quantity over quality has placed new emphasis on what constitutes “quality” in healthcare. Since value-based care reimbursement strategies center around the quality of services delivered, it is critical to identify what exactly that term means-and how it is measured-lest it adversely affect healthcare providers’ revenue streams.

The Agency for Healthcare Research and Quality denotes six domains of healthcare quality, including effective, efficient, timely, safe, patient-centered, and equitable. These measures can be combined and leveraged differently in varying value-based care deals, but are all critical areas for value-based care success, as many contracts require that certain quality measures must be met before payment.

Effective and efficient care are a joint effort that centers around ensuring that hospital patients receive proper care and the resources to coordinate future care to reduce readmission rates.

Since it is difficult to measure effectiveness or efficiency directly (as outside factors can affect readmissions or patient health despite a practitioner’s thorough care) many value-based care arrangements instead assess whether or not the provider has taken the appropriate steps to deliver a level of care that could have prevented readmission barring extenuating circumstances. This helps to reinforce a high standard of comprehensive care.

Providing prompt patient care can positively affect patient experience and increase quality of care. Difficulty making appointments, or long wait times to get in for an appointment, can negatively affect patient experience and hinder patient care. Delays in care create challenges in fulfilling the tenants of value-based care models, and can hinger the preventative aspects of the model.

Quality care means safe care. Patient safety models are incorporated into value-based care models for obvious reasons, since a major emphasis in these systems is on prevention.

For example, this means that things like preventing secondary infections that could result in preventable hospitalizations can be a key quality measure. This is both an effective cost-saving strategy, as well as a benefit to the patient. An emphasis on providing safe care that prevents extraneous complications is a positive result for both payer and patient.

Patients want to feel like they are being listened to and that their providers care about their health and well-being. Patient-centered care checks off these boxes to provide a more fulfilling patient experience. This can also come as a result of increased patient compliance and more effective coordination of care, which is rewarded by value-based care models. 

A tricky quality measure to evaluate quantitatively, equitability is nonetheless critical in value-based care models. Equity quality measures encourage providers to provide care to patients from every portion of the population, regardless of demographic.

Many value-based care arrangements put an emphasis on-and reward practitioners for completing-preventative screenings. However, reimbursement is often contingent on screening rates being comparable across these different demographics, which encourages equitable care across all populations.

An important consideration in healthcare equity includes understanding and addressing social determinants of health, such as the economic status of patients. To date, most healthcare equity efforts have centered on community health programs-programs that don’t always meet the standards of care in a value-based payment model.

While value-based care models differ in their emphasis on different quality measures-often due to the needs of the target population-all of them play an important role in every model since they are so interconnected. Only by providing quality care will value-based care models be successful.

Laura Dorr is a freelance writer based outside of Cleveland. She has served as a writer and editor for a variety of publications and websites across the medical, dental, sports, education, and nonprofit industries.

Articles

In the shift from quantity to quality, there are five critical areas where quality is critical.

5 Quality Measures That Matter for Value-Based Care

It goes without saying that value-based care is growing in the United States. An 

 of the model from Definitive Healthcare, found that 48 states now have value-based care programs-up from just three in 2011.

While the value-based care model is growing, there are still several major barriers when moving to such a system. In a recent survey polling 1,090 healthcare leaders across various sectors, respondents identified five main challenges to shifting to a value-based model.

Here are the five barriers from least to most critical:

5. Difficulty collecting and reporting patient information

Approximately 14.8% of respondents reported that having trouble accessing patient information was a challenge that providers face when transitioning to a value-based care model.

 Since value-based care is centered around practitioner coordination, easy access to patient records and data is critical for successful wraparound care. Inaccessible patient information creates a huge barrier to coordinated care, and makes providing effective preventative care nearly impossible.

While almost 15% of those surveyed found this to be a critical issue, the adoption of more efficient ways to share patient data-such as online platforms-being implemented by many healthcare systems and practices push this problem to the bottom of the list for most of those surveyed.

Continuously evolving value-based incentive programs continue to be a big barrier for 16.2% of survey respondents.  Since the introduction of incentives from the Centers from Medicare and Medicaid Services weren’t mainstream until 2012, regulations and policies have been constantly introduced and modified.

These changing regulations have made the shift from a fee-for-service model a challenge, as healthcare practitioners struggle to navigate the shifting value-based incentive programs.

3. Financial risk and unpredictable revenue streams

Many respondents reported that the bottom line of challenges they face was just that: their bottom line. Fears about revenue stability and sustainability when adjusting to a value-based payment system were reported by 17% of those surveyed to be a big barrier to switching to the value-based model.

In addition to concerns about unpredictable effects on their revenue stream, these respondents also cited difficulty understanding the financial complexities involved in value-based care incentive programs and the transition to these programs. Essentially, an overall lack of understanding of the financial risk of adopting a value-based care model was a formidable barrier.

2.  Technology interoperability challenges

Gaps in interoperability were the second-highest reported barrier for respondents. Much like those who reported concerns about collecting and reporting patient information, the 19.7% of participants who cited inoperability as a barrier were deeply concerned about the difficulties of data exchange.

The adoption of electronic health record (EHR) systems have been critical in managing the impressive amount of healthcare data and analytics that needs to be shared in a value-based care model. While the implementation of EHR technology has grown drastically since CMS’ meaningful use incentive payments initiative in 2011, 2% of hospitals still do not have EHR systems-many of which are psychiatric facilities, which can be a critical component in value-based care.

The number-one challenge reported was simply a lack of resources. Over a quarter of respondents (25.3%) cited staffing shortages, insufficient healthcare software and other deficits as the biggest barrier to value-based care. Without sufficient resources to make-and support-the switch to this model, it may not be sustainable for many practitioners.

For example, inadequate healthcare software won’t allow healthcare providers to assess and execute critical population health initiatives critical to the success of value-based care. And of course, a shortage of staff necessary for value-based wraparound care-such as registered nurses, behavioral health providers and pharmacists-make it nearly impossible to effectively fulfill the parameters of the value-based care model.

A recent survey found what were the biggest issues facing value-based care.

The Top 5 Barriers to Value-Based Care

The transition to value-based care models is steering physicians away from the traditional quantity-centric parameters of the fee-for-service model, and into comprehensive and individualized care.

This shift is especially beneficial to oncology patients, who are positioned to benefit extensively from a comprehensive care model that allows for personalized care coordination. The complex care needs of oncology patients are best met by an all-encompassing, overarching approach that coordinates resources for comprehensive support.

However, delivering such high-quality, patient-centered care can be complicated for oncologists who also need to maintain the meaningful cost savings necessary to meet the targets of the value-based care programs-particularly as cancer treatment costs continue to rise.

Here are three things to consider regarding the challenges of balancing cost and quality in oncology care.

 surveyed 530 oncologists participating in value-based care programs. Overwhelming, the respondents stated that rapidly increasing drug prices are making it increasingly difficult to keep costs down. 57% of those surveyed cited rising drug costs as the biggest challenge for value-based care models. 87% said that these models make them reconsider drug choices.

As a result, 38% of the surveyed oncologists reported wanting a deeper understanding of drug value and therapy impact, so that they could make better-informed choices to optimize treatment decisions to both benefit patients and also keep costs in acceptable ranges. In fact, half of oncologists said that receiving better data about both cost and care quality would help them make more informed treatment decisions. However, 66% responded that pharma companies have been “not helpful at all” in helping them learn about the holistic value-not just the cost-or their drugs.

How Value-Based Care Changes The Provider Staffing Model

2. Unestablished or underutilized clinical care pathways.

Following and adhering to clinical pathways has been shown to lower cancer-care costs. Pathways optimize workflows to make them more efficient, and are a way to reduce extraneous treatment variability, standardize care and improve outcomes.

However, the survey discovered that 66% of oncologists aren’t utilizing pathways, because they either don’t have access to them, or choose not to follow them. This underutilization-and inaccessibility-can compromise productivity, resulting in added costs. As the value-based care model grows and develops however, 86% of those surveyed reported seeing a role for clinical pathways in their practice in the next two years.

75% of the oncologists surveyed by Integra Connect said that cost targets of value-based care have influenced them to make changes to how they choose treatment regimens, in comparison to their approaches under a fee-for-service model. As lowering costs-without sacrificing patient care-becomes a priority, physicians need to embrace comprehensive care that offers solutions before costly interventions become necessary.

For example, avoiding expensive hospital admissions can reduce cancer care costs. Providing more access to outpatient care, conducting advance care planning and offering disease management programs can lower hospital admission rates. Strategies such as care coordination and palliative care can not only reduce emergency room visits and hospital stays, but also improve a patient’s quality of life.

Implementing these programs and creating care networks can be costly in the transition phase, but will, in the long run, make value-based care models financially sustainable for oncologists. Integrating these strategies into treatment plans can help keep costs down, while also providing improved patient care.

Laura Dorr is a freelance writer based outside of Cleveland, Ohio. She has served as a writer and editor for a variety of publications and websites across the medical, dental, sports, education, and nonprofit industries.

What to consider when balancing cost and quality in oncology care.

Maintaining Oncology Cost Savings: 3 Challenges in Value-Based Care

As the industry transitions from the fee-for-service model to value-based care, many providers are finding themselves struggling to straddle the divide. The shift away from volume has created many new administrative burdens that are handicapping providers’ ability to focus on patient care.

In an effort to alleviate these significant provider burdens, CMS recently sent out a request for information to various organizations-including the 

Medical Group Management Association (MGMA)

-on how they can better streamline the process.

AMGA proposed several reforms, saying in a 

 that “[We have] recommended that [CMS] reform a number of regulations and policies to ensure they support providers’ ability to deliver care in value-based model … [including] detailed policy recommendations designed to reduce Medicare programs’ regulatory complexity so our member providers are better able to focus on providing the best possible patient care.”

The recommendations from the AMGA and MGMA include:

1. Synchronize rules and regulations across programs.

Differing rules and regulations across risk-based and non-risk models create extra complications for providers. Within the Medicare Shared Savings Program (MSSP) the rules currently governing the accountable care organizations (ACOs) shift based on the ACO’s accepted amount of financial risk. Waivers are restricted based on this level of risk.

However, the AMGA believes this is counterproductive and should change, and that even non-risk based ACOs should be allowed to deliver coordinated care using the appropriate waivers. The organization stated in their 

 that “providers that participate in these value-based arrangements should enjoy a consistent regulatory framework and have access to the tools that support their ability to deliver the highest quality care to their patients. The only meaningful difference among the levels of the MSSP’s glide path should be the level of financial risk an ACO faces as it progresses.”

AMGA also commented that the regulations developed in the fee-for-service model don’t account for the investment that providers must make to transition to value-based care and population health models. “Limiting waivers and beneficiary incentive opportunities to a subset of ACOs creates a situation to adjust how they deliver care with no benefit to patients,” the letter concludes.

2. Simplify quality measurement reporting.

An overly-complex system for quality reporting in value-based care models is a huge burden for providers, requiring excessive amounts of time and manpower, as well as complex IT infrastructures-which leads to increased costs. 

AMGA suggested CMS scale down the amount of quality measures for value-based care providers. “Using a standard set of value measures will help reduce the variation in the measures that are reported and help eliminate unnecessary confusion and administrative burdens,” AMGA wrote in their comment letter to CMS. AMGA suggested that CMS use a set of 14 process and outcomes quality measures approved in 2018 by the association’s Board of Directors.

“Given the immense provider burden with very little added value, the Medicare program should reduce the number of quality measures for all value-based providers and more to a more outcomes-based system supported by claims data,” the comment letter added.

MGMA agreed and further advised that CMS evaluated a reduction in quality measures used in the Medicare Merit-Based Incentive Payment System (MIPS). MGMA stated in their 

 that MIPS, a relatively new pay-for-performance modes for providers billing under Medicare Part B, should be structured “to allow practices to prioritize effective and impactful improvements to patient care, rather than comply with sprawling reporting mandates.”

 (or “self-referral law”) was enacted to prevent healthcare fraud, and prohibits physicians from referring patients needing certain services paid for by Medicare to other providers or entities with which they have a financial relationship. (The federal government defines “financial relationship” as any direct or indirect ownership or investment by the referring physician or their immediate family members.)

However, this law was designed under the fee-for-service model. MGMA asserts that the law needs to be adapted due to the new requirements of value-based care models, stating “with each successive CMS rulemaking under the Stark Law, the regulatory scheme has become more complex, to the point where it is now virtually unfathomable to all but the most specialized attorneys and compliance consultants.”

This administrative burden means that smaller organizations may struggle to ensure their providers comply with the self-referral law, as they aren’t able to afford the resources to evaluate compliance. This, asserts MGMA, is a huge impediment.

CMS reform should “account for physician group practices of all sizes and specialties and offer protection to all medical groups that participate in or contribute to innovative payment arrangements as a component of a larger entity,” the organization states. A modernized version of the law, MGMA says, should include an overarching compensation exception for the providers taking part in alternative payment model systems, while also taking into account the group practice model and allowing for the coordination of care.

“Considerable work must be accomplished to overcome the numerous technical, legal and logistical barriers,” the MGMA comment letter concludes. “CMS has taken on the formidable task of reshaping public policy in an effort to create a healthcare environment that leads to improved patient care and more efficient delivery of care. We look forward to continuing to work with CMS and other federal agencies to facilitate practice transition.”

Medical groups offer new ways to help better streamline the model.

3 Reforms Aim to Reduce Administrative Burden of Value-Based Care

1. Patients spend less money to achieve positive health outcomes.

Medical care can be costly, particularly for patients with chronic diseases, such as high blood pressure, diabetes, heart disease, or cancer. Value-based care places an emphasis on finding cost-effective, efficient treatment plans, while also supplying the skills to avoid chronic disease altogether. Since value-based care promotes prevention-based services, in the future patients will have less need for medical services such as emergency room visits, lab testing, or imaging studies.

 tracked changes in spending, implementation, and quality of care over eight years of Blue Cross Blue Shield of Massachusetts’ Alternative Quality Contract (AQC) model.

The study found that the average annual medical spending for AQC program enrollees was $461 lower than patients not enrolled in AQC. This 11.7% savings on claims stemmed from lower prices and long-term reduction in the need for services, including an overall drop in future emergency room visits. AQC enrollees had smaller growth in average medical spending, with savings continuing to deepen over time, correlating to the increased use of prevention-based patient services.

2. Providers get rewarded for effective care.

The shift to prevention-based care means that providers can spend less time-and money-treating chronic disease. This encourages providers to find new ways to provide comprehensive care to improve outcomes and patient satisfaction.

Value-Based Care: Gaining Ground or Losing Steam?

Unlike fee-for-service models, value-based care allows practitioners to focus on what the best treatment is for their patient, rather than what is the costliest. When the focus is on value instead of volume, quality of care increases. And, under value-based care models, when quality of care increases, so do the financial rewards to the provider.

For example, the AQC model provides practitioners, hospitals, and medical centers with financial incentives and reimbursements for controlling costs while improving quality and meeting targets related to patient care and satisfaction.

Value-based models encourage a team-oriented approach to patient care. Under a value-based model, medical care is not siloed. This means that primary, specialty, and acute care are integrated, and that healthcare providers work as a networked team to deliver the best coordinated care. For example, treatment plans may require the contributions pharmacists, behavioral health providers, social services, specialists, and more. Each contributing party shares in the incentives of a positive outcome.

This provides comprehensive, coordinated care, while also allowing outcomes to be easily measured through shared patient data-particularly important since value-based incentive payments are based on outcome. Shared patient data can also reduce redundancies in care, preventing unnecessary costs.

This shared value-based approach differs greatly from the traditional fee-for-service model where providers are incentivized to individually order more procedures and tests to get paid more-while increasing costs to patients.

New research has shown the system has concrete benefits for both patients and providers.

Three Reasons Why Value-based Care Works

With more health systems looking to partner with physicians for advanced comprehensive care, primary care is one of the most sought-after specialties for evolving value-based care initiatives. As more value-based care models begin to target primary-care and private practices-and the trend away from fee-for-service progresses-providers need to be prepared.

, 63% of primary-care physicians said that they believe value-based care would have a negative impact on their practice financially. While practices need to evaluate the health needs of their communities to see which system is most appropriate, over the long run, value-based care can be quite lucrative for primary care.

However, in order for the transition to this model to be profitable, practices need to take the appropriate steps to support the shift. This includes being properly staffed.

Traditionally, in a fee-for-service revenue model, the medical-assistant model for staffing has been the most cost-effective option, according to a recent 

 by Premier. The Bureau of Labor Statistics reports that the median pay for medical assistants in 2018 was $16.16 per hour-a dramatic savings from the $34.48-per-hour pay made by registered nurses. Additionally, the study did not uncover any correlation to higher levels of productivity in practices with a more diverse skill mix.

However, while effective for practices that are fee-for-service revenue based, this staffing approach may not be able to support the new models designed to provide comprehensive care. As practices transition into value-based care, a higher skill mix becomes crucial for success, in order to support a more coordinated model of care for patients. This coordination is critical, as value-based arrangements require a combination of technical, clinical, and administrative aspects.

Why Engaging Providers in Value-Based Care Will Be Even More Critical in 2019

For example, patient education, clinical care planning, and treatment implementation will all need to be incorporated under the value-based payment model. Such a comprehensive care package could include the work of RNs, pharmacists, behavioral health providers, or more.

“Primary care is one of the highest priorities for health systems as they move to value-based care and payment models,” Chris Smedley, vice president of Physician Enterprise Services at Premier said in a statement. “However, many primary care clinics are still operating under fee-for-service and lack the insights necessary to effectively adjust their operating models as they transition to value.”

While staffing with a higher skill mix may seem less cost-effective at first glance, providers will need this variation to provide the successful outcomes necessary for revenue under the value-based models. For the 22% of primary-care providers currently operating on a medical assistant-only model, this presents some complications.

These practices will need to integrate more specialized skill sets into their practices, such as registered nurses, social workers, pharmacy support staff, or other licensed professionals. These changes will be an investment; that this model will be more expensive, particularly at the start, than a medical assistant-only model goes without saying.

However, in the long run, these investments into an efficient staffing model will pay off, particularly as practices begin to become eligible for incentive payments or other value-based reimbursements.

“As the industry moves toward value, participating in risk-based models will become a more viable option for many to ensure financial success,” Smedley said. “The key is to appropriately evolve staffing models as organizations shift to managing the health of their populations.”

Why new payment models require new staffing considerations.