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The fate of the Affordable Care Act is still to be decided, but it’s likely that several provisions related to cost, quality, and patient satisfaction will continue to merit attention, including initiatives that reward providers for higher quality care, effective care coordination, and better clinical outcomes.
The fee-for-service model that rewards providers for more tests and more procedures, regardless of outcomes, is clearly outmoded, wasteful, and inefficient. Any serious attempt to improve healthcare must recognize that both coordinated care — the integration of primary care, specialized care, and ancillary services — and value-based care will be foundational moving forward. Reversing the policies and practices that have led to years of fragmented, disjointed, and episodic care will be challenging, but essential.
The U.S. Department of Health and Human Services (HHS), which administers Medicare, now categorizes healthcare payments into four categories, each with different criteria for payment. Category 1 is fee-for-service based, with no link to quality. Category 2 combines fee-for-service with quality. Category 3 is based on “alternative payment models” that use “fee-for-service architecture.” And Category 4 consists of population-based payment, a model in which providers “are accountable for patient-centric care for a specific population over a fixed timeframe and across the full continuum of care.”
The stated goal of HHS was to have 85% of Medicare fee-for-service payments in Categories 2, 3 and 4 by the end of last year and 90% in those categories by the end of 2018. Meanwhile, it aimed to have 30% of Medicare payments in Categories 3 and 4 by the end of last year (a goal it says it reached almost a year ahead of schedule) and 50% in Categories 3 and 4 by the end of 2018.
How? Through Accountable Care Organizations (ACOs), advanced primary care medical home models, new bundling models for episodes of care, and integrated care demonstrations for dual Medicare-Medicaid enrollees.
Meanwhile, the Council of Accountable Physician Practices has set out to determine how well the push for coordinated care is progressing. The verdict as of midway through 2016: Coordinated care is improving, but there’s still a long way to go.
For example, 60% of patients said their primary doctors had access to their hospital or emergency room records. But only 49% said their doctors were able to share information about their health, and know their history before their appointments.
The need for coordinated care may be especially acute for older patients, who are more likely to have trouble navigating the mazes that characterize traditional healthcare models. Another survey found that 34% of elderly patients, many of whom have have multiple chronic conditions requiring multiple providers, relied on family members to help coordinate their care, and 35% had no help at all.
Care coordination, says the National Academy of Medicine, has the potential to make the health care system more effective, safer, and more efficient. But many common communication gaps still need to be overcome. For example, patients don’t always know why they’re being referred to specialists. Specialists don’t always know why patients have been referred to them or what tests have already been done. And primary care physicians often aren’t told what happened during a referral visit.
Nonetheless, studies show that highly rated care coordination produces good patient outcomes, lower costs, and improved access to care.
Of note, two trends may help shed light for providers who are attempting to shift to coordinated care and value-based models. One is that coordination of care has been easier to implement in rural regions. The other is that it requires successfully implementing digital health technology.
Rural hospitals with smaller numbers of doctors and healthcare sites, have, as a whole, done a better job of cultivating collaboration among primary care doctors, referral hospitals, and post-acute care providers. Though rural facilities have fewer patients, which makes it harder to move toward a value-base model, investing in technological infrastructure like EHRs, which are required for value-based models, appears to have paid off for those who’ve done it.
Meanwhile, the role of EHRs has shifted away from fee-for-service applications in recent years to accommodate care coordination and value-based models. Universal EHRs now allow doctors easy access to medical histories and comments from other doctors.
Physicians may balk at the time needed to enter patient information, but integrated digital health technology will be required to achieve strong levels of care coordination and value-based care.
As CMS continues to emphasize quality metrics and patient perception of care, data collection is one of several areas in which scribes can have a direct impact on whether hospitals are rewarded or penalized for their degrees of success in delivering value-based care.