Question

Provide recommendations for strategies that will position hospitals for viabilty and future value creation with Value based reimbursement models. What should hospitals do diferently to prepare for the future? How should the model of care change and how does this help creat value?

Answer 1

In health care, the days of business as usual are over. Around the world, every health care system is struggling with rising costs and uneven quality despite the hard work of well-intentioned, well-trained clinicians. Health care leaders and policy makers have tried countless incremental fixes—attacking fraud, reducing errors, enforcing practice guidelines, making patients better “consumers,” implementing electronic medical records—but none have had much impact.

The transformation to value-based health care is well under way. Some organizations are still at the stage of pilots and initiatives in individual practice areas. Other organizations, such as the Cleveland Clinic and Germany’s Schön Klinik, have undertaken large-scale changes involving multiple components of the value agenda. The result has been striking improvements in outcomes and efficiency, and growth in market share.

There is no longer any doubt about how to increase the value of care. The question is, which organizations will lead the way and how quickly can others follow? The challenge of becoming a value-based organization should not be underestimated, given the entrenched interests and practices of many decades. This transformation must come from within. Only physicians and provider organizations can put in place the set of interdependent steps needed to improve value, because ultimately value is determined by how medicine is practiced. Yet every other stakeholder in the health care system has a role to play. Patients, health plans, employers, and suppliers can hasten the transformation—and all will benefit greatly from doing so.

Five STEPS to prepare your practice for value-based care:

1. Identify your patient population and opportunity.

2. Design the care model.

3. Partner for success.

4. Drive appropriate utilization.

5. Quantify impact and continuously improve.

STEP 1 Identify your patient population and opportunity.

Knowing your patients is the foundation of value-based care. Patient populations with the highest risk of hospitalization or high utilization of the emergency department (ED) tend to drive high health care costs and most often receive fragmented care. These populations often include poly-chronic patients — those with chronic and complex conditions with multiple co-morbidities, such as diabetes, hypertension, depression, heart failure, cancer, kidney failure, or chronic obstructive pulmonary disease.

Understanding which patients drive your highest cost of care and those who use the ED frequently will help you to identify your target population and opportunities for improvement. Once you have this information, you can begin to develop your model.

• The American Medical Association (AMA) recognizes that the physician is best suited to assume a leadership role in transitioning to alternative payment models (APMs). As such, the AMA supports that the following goals should be pursued as part of an APM:

  1. Be designed by physicians or with significant input and involvement by physicians;

  2. Provide flexibility to physicians to deliver the care their patients need;

  3. Promote physician-led, team-based care coordination that is collaborative and patient-centered;

  4. Reduce burdens of Health Information Technology (HIT) usage in medical practice;

  5. Provide adequate and predictable resources to support the services physician practices need to deliver to patients, and should include mechanisms for regularly updating the amounts of payment to ensure they continue to be adequate to support the costs of high-quality care for patients;

  6. Limit physician accountability to aspects of spending and quality that they can reasonably influence;

  7. Avoid placing physician practices at substantial financial risk;

  8. Minimize administrative burdens on physician practices; and

  9. Be feasible for physicians in every specialty and for practices of every size to participate in.

• Are there guidelines to help medical societies and other physician organizations identify and develop feasible APMs for their members?

  Yes. The AMA recommends that the following guidelinesare considered:

  1. Identify leading health conditions or procedures in a practice;

  2. Identify barriers in the current payment system;

  3. Identify potential solutions to reduce spending through improved care;

  4. Understand the patient population, including non-clinical factors, to identify patients suitable for participation in an APM;

  5. Define services to be covered under an APM;

  6. Identify measures of the aspects of utilization and spending that physicians can control;

  7. Develop a core set of outcomes-focused quality measures including mechanisms for regularly updating quality measures;

  8. Obtain and analyze data needed to demonstrate financial feasibility for practice, payers, and patients;

  9. Identify mechanisms for ensuring adequacy of payment; and

  10. Seek support from other physicians, physician groups, and patients.

• Can CMS or private payers provide support to implement successful APMs?

  Yes. CMS and private payers can support the following types of technical assistance for physician practices that are working to implement successful APMs:

  1. Assistance in designing and utilizing a team approach that divides responsibilities among physicians and supporting allied health professionals;

  2. Assistance in obtaining the data and analysis needed to monitor and improve performance;

  3. Assistance in forming partnerships and alliances to achieve economies of scale and to share tools, resources, and data without the need to consolidate organizationally;

  4. Assistance in obtaining the financial resources needed to transition to new payment models and to manage fluctuations in revenues and costs; and

  5. Guidance for physician organizations in obtaining deemed status for APMs that are replicable, and in implementing APMs that have deemed status in other practice settings and specialties.

• Does my patient's insurance plan matter?

  A patient's insurance plan does not influence the quality of care patients receive; however, the insurance plan does impact -the services and benefits that can be offered to the patient in order to keep his or her out-of-pocket expenses to a minimum. Moreover, many insurance plans are incorporating Value-Based Insurance Design (VBID), through which patients' cost-sharing can vary to encourage use of high-value care or discourage use of low-value care. This is an opportunity to align goals of value-based payment with clinical and financial incentives for patients.

STEP 2 Design the care model.

Develop care models that are evidence-based and easy to follow.

You can consider the following elements in the development of your value-based care model:

• Identify the target patient population(s).

• Identify which payers will be involved.

• Estimate how the type and volume of services will change. Involve your legal advisors at the outset so you are aware of and design the program in compliance with federal and state laws.

• Identify the benefits expected for patients and payers.

• Design the workflows required to provide the desired care to the selected patient population.

• Discuss details including:

  • Team members who will support the new model.

  • Roles and responsibilities of each physician and the care team.

  • Frequency of patient contact (via phone call, email, or portal messaging).

  • Frequency of patient visits to the practice or from home health care.

• Identify measurable success metrics for each population, and determine your baseline in order to quantify your impact in the future. Your metrics should be easy to capture in the electronic health record (EHR) or population health registry to prevent having to extract them manually.

• Identify transition costs (as a note, revenue needs to be addressed as well as risk-stratification).

Depending on the licensure, education, and training of your team, current team members could potentially fill the staffing needs of the new value-based care model with proper education and redistribution of responsibilities. Utilizing current staff can be cost effective during the initial transition period, but additional staff may be needed as the model continues to be adopted by the practice, particularly since value-based models rely heavily on effective care coordination and require a greater amount of data capture and analytics.

The care team should be led by a physician to identify, engage and elicit from each team member the unique set of training, experience, and qualifications needed to help patients achieve their care goals, and to supervise the application of these skills.⁸

Roles of other team members who care for patients in the model could include:

• Patient outreach coordinators.

  Non-clinical team members who can utilize patient registries and analytic tools to reach out to patients who need additional assistance from a variety of care team members.

• Nurse educators/navigators.

  Registered nurses with specialized training in appreciative inquiry, motivational interviewing, health coaching, and case management can positively impact the health of patients by extending the traditional reach of providers and their clinical care teams. They can intervene with the most vulnerable populations between office visits to educate and assist them in better managing their chronic health conditions. Registered nurses can schedule appointments and cover patient education, as well as provide the hands-on support and partnership that patients need to improve their health.

• Care coordinators.

  Medical assistants (MAs) with training in population health management, clinical documentation, and quality improvement can work closely with the nurse navigators to provide follow-up communication and care coordination for high-risk patients. MAs can routinely check in with patients to support adoption of healthy behavior changes and work independently or with patient outreach coordinators to identify and close care gaps through patient engagement.

• Certified medical assistants (MAs).

  Certified MAs (CMAs) can perform medical record reviews for patients scheduled for upcoming clinic visits, coordinate daily huddles, obtain all pertinent vitals and labs, complete medication reconciliation, and set the visit agenda with the patient, in accordance with state law. In this more advanced MA role, the CMA has the opportunity to start identifying gaps in care in preparation for the physician visit and then document the visit while in the room with the physician. After the physician finishes the encounter, the CMA makes sure the patient understands the plan of care and answers any questions. This type of workflow allows the provider to focus more on the patient and ensure that all the patient's needs are met during a single office visit, thereby increasing provider productivity and quality, while reducing clerical burden. While working within his or her scope of practice, the CMA is able to answer patient questions and coordinate patient care after the visit, providing continuity and consistency for patients.

• Referral coordinators.

  Employees responsible for both scheduling referrals and obtaining any precertification required by the patient's insurance company are referral coordinators. Referral coordinators also communicate with the patient to confirm that the next appointment is kept. Referral results are obtained by the referral coordinator and scanned into the patient's medical record or sent electronically for the physician to review, if needed. If any follow-up care is needed, the coordinator can connect with the patient and schedule the proper appointment. Referral coordinators must be mindful of applicable federal and state laws including those that prevent patient steering and protect patient choice.

• Transition of care nurses.

  Nurses can provide support and care coordination services to patients undergoing a transition between different levels or venues of care. This function requires meticulous attention to the details of a patient's care, including, but not limited to: medication reconciliation, discharge instructions, resource availability for outpatient or community-based care, and provider follow-up within a defined time frame. In your practice, these nurses could make sure that patients who are seen in the hospital or ED receive the follow-up care they need in the practice by scheduling those appointments.

• Extensivists and hospitalists.

  The extensivist team works alongside the hospitalists, ensuring that patients receive the appropriate follow-up care and care coordination after they are discharged. Hospitalists and extensivists work hand-in-hand with care transition teams to ensure that proper follow-up care is received and understood by the patient and care team.

A “Model of Care” broadly defines the way health services are delivered. It outlines best practice care and services for a person, population group or patient cohort as they progress through the stages of a condition, injury or event. It aims to ensure people get the right care, at the right time, by the right team and in the right place

The process for developing a MoC is illustrated in the flow chart. The key steps are listed below and will be described in detail.

Project Initiation: Identify services for review, begin to build a case for change, obtain sponsorship to proceed with the program of work and set up project management mechanisms.

Diagnostic: Define the extent of the problem and understand the “root cause” to address the real problem.

Solution Design: Develop and select solutions. Create and document the MoC.

Implementation: Support the health system to deliver the changes needed to implement the MoC.

Sustainability: Optimise use of the MoC, monitor the results and evaluate the impact.