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Value-Based Reimbursement: The Resources and Elements that Lead to Success

For healthcare facilities, transitioning from traditional fee-for-service models to value-based care is like committing to a grueling physical fitness program. At first it’s bound to hurt a bit, but the effort is going to pay off. And the sooner you start, the better off you’ll be.

Value-based care is slowly but surely becoming the norm. But embracing the change may require providers to sacrifice profits, at least in the short term. Furthermore, no one can say with certainty how long it might take a given hospital to reverse the trend — to begin to grow revenue through value-based reimbursement at a faster pace than it loses traditional fee-for-service revenue.

What is certain is that providers who don’t adapt will be left behind. That’s according to Laura Kaiser and Thomas Lee, MD, who, writing in the Harvard Business Review, add that they see “a compelling business case for acting now to achieve value-based care without worrying about when the market will make the shift.”

Long-term strategy

Ms. Kaiser, Executive Vice President and Chief Operating Officer of Intermountain Healthcare, and Dr. Lee, a Harvard professor and Chief Medical Officer at Press Ganey, cite four instances of providers who’ve made the plunge. “In all four examples, the organizations’ short-term financial hits were real and painful,” they say. “Nevertheless, we don’t consider these efforts to be acts of charity, but acts of strategy.”

One example: At Mayo Clinic, surgeons who perform lumpectomies or partial mastectomies invest expensive extra time in the operating room to work with the facility’s pathology lab, and determine right then and there whether they’ve removed all the cancer. If they haven’t, they can immediately extend the surgical excision. The approach eliminates about 96% of repeat lumpectomies. Surgical costs are higher, and there’s less revenue to be earned from follow-ups, but overall, medical costs are reduced, and patients get peace of mind more quickly.

Three keys

Granted, stress Kaiser and Lee, short-term losses in the interest of long-term gains are easier to stomach when organizations have financial stability, positive relationships with physicians and advanced information systems.

But the needed investment, they add, is as much in leadership as it is in dollars.

Ultimately, providers are more likely to succeed if they recognize and manage the full continuum of care, focus on both prevention and intervention, and use evidence-based practices to ensure appropriate utilization.

More ingredients

When researchers for the American Hospital Association interviewed leaders at seven hospitals and health systems that were moving forward with the transition, several keys to success emerged, depending, in some cases, on the type of model being used (shared savings, bundles, shared risk or global capitation). Among those noted were:

  • Buy-in on the part of physicians and clinical leadership
  • A culture that’s aligned with organizational structures
  • Control throughout the care continuum, since providers are responsible for outcomes and costs even after patients are discharged
  • An understanding of population health and quality measures (so value-based reimbursement contracts can be better negotiated)
  • Affiliation and participation agreements with providers
  • Clinical protocols and coordinated workflow processes, especially in relation to discharge planning
  • Quality and utilization benchmarks and standards
  • Quality improvement and chronic disease management programs (since patient engagement is extremely important)
  • Registries and performance dashboards that track and report quality targets, and are accessible to all network providers
  • Technology capable of risk-stratifying patients and identifying high-cost patients, as well as being able to report and analyze quality, utilization, and financial metrics

Ultimately, the new paradigm is about eliminating waste, improving quality, and reducing costs. Payers can be expected to be attracted to the hospitals that are among the top performers. They’ll urge their members to use those high-performing facilities and incentivize them to do so. Patient volume will be the key to overcoming the initial loss of revenue.

Help is available

Moving from quantity of patients to quality of care is less daunting with assistance from CareThrough, which has leveraged more than 30-million patient encounters to help providers make the transition.

CareThrough’s expert care team assistants specialize in engaging patients to ensure that the right information is always recorded and conveyed; removing barriers, such as income, insurance, accessibility and availability; and coordinating care at every stage with regular check-ins and coaching.

Value-based care requires an entirely new way of thinking. Managing all the moving parts can be taxing and time-consuming. CareThrough eases the burden by identifying at-risk patients, closing gaps in care, and providing ongoing population health management services.

Care Navigators
As healthcare business models evolve, so should care teams.

Patients who are paired with Care Navigators report feeling less anxiety, and an increased ability to self-manage their conditions between visits. And providers report increased job satisfaction from improved efficiency, and knowing their patients have access to care teams, and strategic support.

LEARN MORE AT CARETHROUGH.COM
Chronic Care Management
With an increased aging population managing two or more chronic illnesses, extending your care teams’ ability to communicate with patients is critical. We take a strategic approach to helping patients chart a path towards their health goals, while self-managing their chronic conditions between clinical visits.

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AI Chatbots
We deliver a robust AI Chatbot solution to help manage and sustain effective communication with patients. Care teams implement the conversational text messages and customize patient communication to deliver high quality care.

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Nurse Care Team Assistants
Adding a qualified Nurse CTA to the care team increases quality of work-life and reduces stress on nurses. The nursing profession is also experiencing an alarming shortage due to increased clerical burdens and burnout.

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Revenue Cycle Management
Transition Revenue Cycle Management into the modern age with a suite of software tools that will transform your billing and coding processes. Transact at lightning speed, with increased transparency and decreased siloes. The QueueLogix software application seamlessly integrates with existing EMRs to ensure the clinical activities and back-office operations are well aligned, monitored and successful.

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Referral Management
Referrals scheduled by navigators in the clinical setting builds long term, patient care integrity across the care continuum. With the authority, along with the provider to search for specialists in network, navigators assess their schedules, and ensure appointment compliance.

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Scribe Services
There’s a reason why we’re the nation’s most frequently used scribe company: we offer professionally trained medical scribes to meet the specific needs of our clients. We offer a variety of scribe programs, as well as technology and personnel solutions that address revenue cycle management, the transition to value-based care, and more through our HealthChannels family of companies.

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