What does it mean for you if all Medicare beneficiaries have been shifted to value care by 2030?

To grow as a medical provider, you need an effective strategy for converting from a fee-for-service approach to a fee-for-value approach.

Evaluation and management (E/M) guidelines were traditionally based on a fee-for-service approach to billing. But given the strains on revenue and operating margins of recent years, business as usual is no longer financially viable. To optimize reimbursement, payer contracts, and growth opportunities, you need truly patient-centered approaches.

Healthcare costs have risen over the years, and payment programs have been shifting toward a focus on quality rather than services performed or time spent. Increasingly, the emphasis is on providing quality care at a lower cost.

The Center for Medicare & Medicaid Innovation has promulgated a goal of “transition[ing] virtually all Medicare and Medicaid beneficiaries into accountable care relationships by 2030.” Payers, employers, and the federal government are embracing the new model. Organizations that fail to make the transition may not survive.

Levels of Value-Based Care

Value-based care exists on a continuum. On one end, we have fee-for-service and a narrow episodic care perspective; on the other, a broad population-health perspective.

Under the fee-for-service approach, providers minimize their risk by being paid for their time. This type of care involves reimbursement rates that have not kept up with inflation, and requires an increase in physician productivity in order to be profitable – a strategy that can lead to physician burnout and poorer quality of care.

As quality measures are introduced, and providers attain measurable targets, pay for performance becomes essential. The next step is a bundled-payment model where one payment is made for all the discreet services utilized across a clinically-defined episode of care. Here providers are rewarded for effectively managing groups of patient conditions.

Eventually, as trends emerge, provider groups can pursue a patient-centered strategy for improving the health of populations that addresses risk through a model of shared savings, global payments, and even full capitation.

Planning for the Pivot

While all clinicians are motivated toward quality, an organization must adopt a strategic plan to maximize value-based care.

To ensure success, it is critical to engage leaders and clinicians, securing buy-in from decision-makers and providers. Plans require accurate, hard-hitting data to show where the department is, where there may be room for improvement, and what new processes or quality initiatives will make the most significant impact.  Also, relationships with health systems and payers, and knowledge of healthcare gaps in the community, will help identify initiatives where improving quality may yield better outcomes and savings. To continuously improve quality, each initiative must be fully integrated into care and interdisciplinary processes, and the benefits of the initiatives must be verified.

Measuring Success

To ensure that it meets and exceeds goals for quality of care, a data-driven organization must create action plans for continuous improvement and monitor the implementation of those plans.

Data is the fuel that powers improvements in quality. Without timely, accurate, and curated data, your team is trying to reach a destination without a roadmap. You need mini-targets, pulse checks to measure performance, and the ability to adjust the plan in light of new information.

Segmenting your data by department, provider, patient population, diagnostic subgroup, payer, time period, and other meaningful criteria should be easy. The data should be available in a broad dashboard-type view — yet also easily analyzed on a granular level to pinpoint root causes for variation in performance.

Powering Quality Initiatives With Data Analytics

Partnering with d2i enables organizations to invest in value-based payment strategies and quality patient care that benefits their communities. By providing the full spectrum of individualized data, from a birds-eye view to fine details, d2i helps you to prioritize and capitalize on quality.

To learn more about how we can help your organization identify high-impact opportunities and actions for performance improvement, as well as monitor the impact of your changes, contact us to schedule a demo of any of our data acquisition and performance analytics solutions.