The healthcare industry is gradually undergoing a shift from the traditional fee-for-service model to a framework built on value-based care. This transformation process is supported by several initiatives from the Centers for Medicare & Medicaid Services (CMS), including programs for specialist clinics; for example, the Enhancing Oncology Model (EOM) incentivizes the adoption of value-based care in oncology. EOM helps place cancer patients in care teams that provide high-value, equitable, evidence-based care, and encourages oncology practices to make cancer care more affordable and accessible. Commercial alternative payment models (APMs) are also here to do, as payers are evolving to more innovative models.
Under value-based care, payers reward quality over quantity by reimbursing providers based on patient health outcomes, rather than the volume of services provided. The CMS defines the goal of value-based care as “better care for individuals, better health for populations, and lower costs.”
If providers can achieve improved practice quality outcomes at a lower cost, they will earn higher reimbursements while simultaneously cutting down on overhead expenses, becoming more marketable to patients and streamlining overall efficiency.
Success in value-based care means demonstrating higher quality of care via evidence-based metrics such as patient health outcomes, spend value, readmission rates, and patient access. The following five strategies contributed to proven success in value-based care programs:
- Investing in IT infrastructure
Value-based care goes hand in hand with the digital transformation of the healthcare industry, aided by technology vendors who specialize in healthcare solutions. The information drawn from gathering, storing, analyzing and transferring real-world clinical data is crucial to finding ways of adding value to your practice. IT systems can be patient-facing (e.g., patient portals, mobile apps that offer scheduling services, medication tracking) or enterprise-oriented tools for staff coordination, administration, and analytics. Some systems, such as electronic health records (EHR), fall into both camps and are essential resources for effective value-based care.
- Data Analysis and Insights
To make progress on the metrics of value-based care, you need precise information on patient outcomes, business processes, drug successes, tests, purchases, and other factors. For example, an oncology clinic could analyze claims data from Monthly Enhanced Oncology Services (MEOS) to gain actionable insights on how to improve results. A specialized analytics platform should be at the center of your value-based care strategy. - Revenue Cycle Management
Revenue cycle management (RCM) digitally manages and streamlines the financial aspects of a healthcare business, including billing, processing insurance claims, challenging denials, collecting outstanding payments, and liaising with a complex network of payer contract requirements along the way. In recent years, many clinics have increased their days spent in accounts receivable while facing a significant shortage in staff qualified in both medical and financial expertise. A revenue cycle solution uses data insights and automated processes to ease the burden of financial admin on clinical staff. It maximizes revenue by finding and implementing efficiency solutions for both value-based care and fee-for-service models. - Preventative Care In Patient Populations
Preventative care is a cornerstone of the value-based model and precision medicine. Your clinic can use population health analytics to identify high-risk patient populations and the treatments most effective for them. The results can also help evaluate equity of access to care, improve health outcomes, reduce emergency admissions, and drive patient engagement. - Partnering With A Specialty Vendor
Shifting to value-based care has many tangible benefits for healthcare orgs, even if they continue to incorporate fee-for-service. A healthcare technology vendor with well-developed systems and experience in your medical specialty can customize precision solutions to your individual practice.
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Sources:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Value-Based-Programs
https://www.cms.gov/newsroom/fact-sheets/enhancing-oncology-model
https://www.cms.gov/newsroom/fact-sheets/oncology-care-model
https://mgma.com/resources/resources/revenue-cycle/not-so-graceful-aging-half-of-practices-saw-days-i
https://www.hfma.org/topics/news/2022/03/healthcare-news-of-note–staffing-shortages-in-hospitals-and-hea.html
https://www.fda.gov/science-research/science-and-research-special-topics/real-world-evidence