The Promise of Value-Based Care
Legislative changes clearing the way for system-wide care orchestration
The long-term management of complex patient journeys within health systems has always been a balancing act between the optimization of care and maximization of revenue in a fee-for-service environment. The fundamental tension that results has been confounded by CMS and HHS statutory regulations around referral profiteering.
Now that the regulatory framework has been reexamined, those tensions are relaxing as the entire industry moves their focus on outcomes and the value of healthcare. Today, the collaborations that were once frowned upon are now encouraged.
The Move to Value-Based Care
The healthcare industry is increasingly focused on value-based care solutions, a trend which has been bolstered by support from the current administration. The value-based model incentivizes providers to manage patient outcomes, as opposed to gross patient volumes. In this model, care journey management is a mutually desired capability by both caregivers and executives - a far cry from the volume-based model of the recent past.
Fee-for-Service Created Bad Habits
In the fee-for-service (FFS) model, providers were compensated for seeing and treating a patient. If the patient needed follow-on treatment or to be seen by a specialist there were few mechanisms to help monitor and guide that journey. Again, confounded by a number of civil and criminal penalties that could be levied on providers if even the perception of impropriety occurred.
The Office of the Inspector General (OIG) for the Department of Health and Human Services (HHS) developed the Federal Anti-Kickback Statute (AKS) to penalize (civil and criminal) providers who were in cahoots to drive volumes and take advantage of the FFS model. The Centers for Medicare and Medicaid Services (CMS), similarly, developed the Stark Law that focused on impropriety between providers that impacted Medicare and Medicaid services and imposed civil penalties upon them. Specifically, arrangements with a focus on referrals, business relationships, acquisitions, and the like are all targets of AKS and Stark due to the volume-based metrics of a FFS healthcare ecosystem.
Moving Toward the Future, Building Better Behaviors
The entire model of care delivery and financial compensation has begun to shift with the move to value-based care. Accountable Care Organizations (ACO’s) and other Value-Based Enterprises (VBE’s) are rapidly becoming the model for care - ensuring recompense for quality, not quantity - and this implicates a number of interesting points for healthcare providers.
Safe Harbors now exist that protect VBE’s and other care providers from the steep penalties of AKS and Stark, allowing an intentional focus on continuum of care management and fiscal integrity.
Risk-managed populations will grow, providing the opportunity for better outcome delivery and tighter fiscal conservancy in large care delivery systems.
Non-managed populations can be intentionally shepherded through the complex web of care with hand-offs between providers and treatment centers monitored and guided in a way that is beneficial to the patients AND providers.
The changes to AKS and Stark usher in a renewed focus on network integrity and provider collaboration from both a care coordination and reimbursement perspective. We are seeing the introduction of roles that are focused on addressing network effects that previously were subject to legislative scrutiny - a huge boon to patients and providers alike.
Supercharge Your Value-Based Insights
As the landscape continues to shift to value-based care and the regulations loosen, most healthcare systems will still remain largely unable to chart the full longitudinal path of their patients and their often messy care journeys.
To that end, Monocle Insights has developed the Care Milieu, a platform for understanding patient journeys, quality outcomes, and network integrity which allows administrators and providers long sought-after, cross-system insights into complete care journeys and patterns of care that will reshape patient lives and reverse the leakage that has plagued US healthcare systems for years.
If you enjoyed this blog, have questions/comments, or would like to learn more about Monocle Insights, please email info@monocleinsights.com or visit our contact page to schedule a demo!
