Value-Based Care Services

Living with a chronic disease or condition like diabetes, cancer, high blood pressure, COPD, or obesity is costly for patients. Value-based reimbursement models focus time on ways of helping patients prevent and avoid chronic diseases before they start. The goal is to manage patients in a manner that achieves high quality health with the appropriate volume of doctor visits, tests, procedures, and prescriptions per year. Provider incentives are aligned with the patient, with a focus on prevention-based practices to help avoid the onset of chronic disease. Value-based payment models can help control costs and reduce risk. The goal is to work towards population health management that is healthier and uses just the right amount of healthcare resources. Value-based programs in the US have the potential to considerably reduce overall future healthcare costs which in 2019 accounted for nearly 18% of Gross Domestic Product (GDP). 

Prescription drug expenses continue to rise at a rate much higher than inflation. Several healthcare industry stakeholders are calling for manufacturers to tie the prices of medicine to their actual worth to patients. Drug companies should center their prices with patient results, and value-based care models may allow those companies to experience the benefits from reduced costs by aligning their products and services with positive patient outcomes.

The adoption of value-based healthcare and prospective payment systems is altering the way physicians and hospitals provide people with care. New value-based programs stress a team-oriented, network approach to patient care management that involves the responsible sharing of patient data, so that care is coordinated. Adoption of healthcare technology like electronic health record systems create a computerized system view, so outcomes can be readily measured. In value-based healthcare models, primary, acute care and specialty care, are united in a coordinated group approach, led by a patient’s primary physician, who directs the patient’s care team. 

Physicians depend on the sharing of access to electronic health record (EHR) data among all members of the coordinated care team. EHR tools must have accurate, evidence based, properly coded, patient information readily available so providers can see encounter notes, test results and procedures performed by other members of the team. Ubiquitous sharing of key program data, with a focus on patient privacy, has the potential to reduce unnecessary care and costs associated with delivering care.

Accountable care organizations (ACOs) are patient-centered care models within which the patient and providers form a business partnership in coordinated care decisions, including sharing data content among team members to benefit the entire patient population. ACOs were primarily designed by the government Centers for Medicare & Medicaid Services (CMS) to account for and deliver high-quality medical care to Medicare patients. For an ACO to receive a value-based reimbursement CMS promotes patients, doctors, hospitals, and other providers to work together to deliver the best possible care at the lowest cost. In some models, providers may share both risk and reward with incentive savings terms to improve readmission rates, quality of care, and patient health results, while decreasing costs. 

This CMS pay for performance approach policy differs from the traditional fee-for-service approach, in which individual providers may benefit by increasing the quantity of health care services, regardless of whether the patient outcomes were good or bad. In the best value-based care models clinical news and insurance claims data are shared between payers and providers. Healthcare analytics data sharing in a CMS pay for performance approach improves critical population health metrics, such as hospital readmissions, patient engagement and spending on unnecessary services, allowing for accurate value-based reimbursement CMS can reimburse well for.

With the change from traditional fee-for-service to value-based care CMS has concluded that long-term healthcare costs will begin to lower, while helping patients learn to lead healthier more productive lives. As the healthcare landscape continues to evolve and the adoption of CMS value-based care models increase, providers need to become better managers of populations of patients.

To assist in the transition to value-based payment models, many physicians, coders and healthcare organizations are choosing to integrate specialized patient-centered software systems into their EHRs to help search and capture all the appropriate conditions of each patient in their population. Some top HCC risk adjustment coding platforms can synthesize the medical record media using artificial intelligence in healthcare like medical machine learning and quickly associate evidence for improved coding accuracy before the claim is even sent. Only with accurate, evidence based documentation of disease and chronic conditions can fair value-based care CMS reimbursements be allocated to providers.