Over the past decade, healthcare providers have increasingly embraced a value-based care (VBC) approach, an initiative driven by the passage of the Affordable Care Act (ACA) in 2010 and awareness of high healthcare costs and access to healthcare racial and socioeconomic inequalities.
VBC is associated with a variety of alternative payment models (APMs) that shift reimbursement for healthcare providers from fee-for-service (FFS) to payment models driven by the quality of care—some more pronounced than others. Data supporting improved patient outcomes and cost-effectiveness of VBC have begun to increase When the Covid-19 pandemic disrupted the healthcare system and revealed that many APMs (as currently structured) did not enable healthcare providers operating in difficult conditions and serving high-risk communities (i.e. those in new-approach environments and people who work in the population) are most in need of health care when they benefit.
While the revelation of structural economic issues has led to some questions about the inherent viability of VBCs, it is worth first exploring potential adjustments and complementary tools to APM that can address these inequalities. When we peered under the hood, we saw that some of the economic deficiencies in VBC may be due to all the too-familiar blind spots on socioeconomic status and health impacts that impact the metrics used to assess performance and manage reimbursement for healthcare providers . APM. Correcting these underlying assumptions and improving data analysis by healthcare providers can go a long way in mitigating financial risk for providers receiving VBC.
What went wrong with VBC during the pandemic?
In the early stages of the pandemic, Covid-19 appears to be the catalyst for healthcare providers to transition to APM. Value-based providers did well in the early days of the pandemic; They have more flexibility to quickly integrate telehealth tools and methods to avoid disruption to patient care, and unlike FFS providers, they have existing mechanisms to bill payers for such services. But over time, the pandemic has revealed two critical gaps in the VBC and APM’s ability to receive fair reimbursement for care providers.
Given the pandemic, VBC’s first question is APM determination Reimbursement based on measures in established areas– Effectiveness, efficiency, timeliness, safety, patient focus and equity. As the pandemic continues, the practical reality of delaying or delaying care has led to worse outcomes for patients with various conditions, increased infectious complications, and higher mortality and costs.
These dynamics impair provider performance on metrics defined by APM, flagging care as ineffective, inefficient, and untimely. In some cases, under some APMs, prescribed quality measures must be met before a care provider can receive payment. These FFS providers’ unconstrained metrics and requirements appear to be particularly stringent in an environment where failure to meet quality standards can be credibly attributable to external conditions rather than the VBC approach itself or the care provider’s Performance. Additionally, while the pandemic has primarily affected patient care in 2020-2021, Quality measures that rely on 2020 data will impact hospital quality reporting and payment plans for years to come, which means that the financial impact of this shortcoming of APM could have long-term implications for those adopting the VBC framework.
A second problem with reimbursement under APM is that patients’ racial and socioeconomic health disparities are unfairly reflected in — or rather, misattributed to — in the “performance” of these providers. This error most severely penalizes the bottom line of providers who treat patients with the greatest risk. For example, People of color are three times more likely to contract Covid-19 than whites due to socioeconomic factorss and suffer higher mortality from Covid-19. Therefore, the risk of not recovering the cost of services due to conditions triggered by extreme events such as a pandemic is most acute for care providers who disproportionately serve those who need them most.
Due to these dynamics, Some care providers who initially adopted VBC are beginning to revert to a more FFS-centric approach.
Revisiting the assumptions inherent in the VBC payment structure
The stress of the pandemic has highlighted how VBCs and their associated APMs affect providers differently, hurting those who serve at-risk communities most severely. However, there is an opportunity to improve the inequity of the system by relying on improved modeling, analysis and data.
For example, the “risk score” currently used to adjust spending measures fails to identify patient needs and As a result, doctors and hospitals may be incorrectly labeled as “inefficient” If they are caring for patients with acute illness or complex problems, or if they are unable to seek treatment due to external forces such as a pandemic. Operationally, different payers may rely on different quality measures that may inadvertently codify socioeconomic biases in payment patterns that favor providers’ treatment of low-risk communities. Re-examining the underlying assumptions built into APM can identify structural biases and opportunities to correct the model.
On the provider side, comprehensive, advanced analytics platforms and digital tools Can help track patient progress, measure success, and reduce costs. Once providers understand how VBC programs and associated APMs work, and their capabilities to operate within them, they can better quantify risks and identify opportunities to effectively improve outcomes. However, data entry and analysis can be time-consuming and confusing, and entering incomplete or inaccurate data can result in patient progress not being captured and providers being cut short. the opportunity to make better use of these tools to ensure adequate reimbursement for all providers, But especially for primary care providers.
At a minimum, providers should be trained to integrate tools such as EHRs, care coordination platforms, and patient health management platforms into their care and patient management. They also need to understand the importance of properly capturing and analyzing data to ensure they get the full value of the service.
Furthermore, many Digital tools are being developed to support the transition to VBC. from tools like Ayton Health Leverage data integration, machine learning, and analytics automation to extend, connect, and analyze health data to improve performance and financial outcomes, such as Enlace Technology Platform and Sieve MD To help optimize billing and collection for value-based payers, care providers looking to optimize the economics of the transition to VBC have a growing selection of tools to help with the transition.
At the same time, software developers should continue to simplify tools, improve user experience, and enable programs to be used correctly and completely. Improved software, data capture and analysis can also help prevent fraud, making it more difficult to manipulate the system through practices such as falsifying potential patient risk levels to distort the impact and financial value of services.
A value-based future
The underlying premise and promise of VBC remains laudable, and the approach retains the potential to cost-effectively improve patient outcomes, especially in high-risk communities. However, for healthcare providers to remain engaged, economics must work for all parties involved and remain dynamic in situations such as a pandemic that rapidly and profoundly impact the healthcare environment.
Unfortunately, the models behind many of the relevant APMs may reflect some of the same blind spots that society as a whole is prone to – judging vulnerable people and those who treat them in incomplete context, misinterpreting environmental barriers to compliance as poor performance, and Inadequate individuals or institutions. APM’s sensitivity to the effects of Covid-19 itself epitomizes this shortcoming, as the effects of the pandemic are also context-driven shifts in patient behavior rather than individual or institutional failures.
By building a better understanding of context and flexibility in APM, and enabling providers to make data-driven choices, we can begin to address the inequity of VBC burdens and help ensure APM remains viable for healthcare providers and attractive.
Photo: Li Hong, Getty Images
