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Healthcare Provider’s Guide to Value-Based Care

Jon-Michial Carter
Written by Jon-Michial Carter

Healthcare providers are expected to deliver high-quality patient care while effectively managing costs and organizational efficiency. To assist providers in achieving both aims, the Centers for Medicare and Medicaid Services (CMS) introduced value-based care as an alternative to the traditional fee-for-service system for Medicare and Medicaid beneficiaries. 

In a value-based care approach, providers are rewarded based on the quality and effectiveness of care, rather than the quantity of services provided. Value-based care promotes preventive care measures to reduce unnecessary medical services and the cost and time required to manage chronic conditions. 

Investments and participation in value-based care are expected to increase, and CMS aims to achieve 100% beneficiary participation in accountable care partnerships by 2030. 

Value-based care offers the potential to lower healthcare costs, reward providers for exceptional care, and improve the quality of life for patients with chronic conditions. In this article, we explore the benefits of value-based care for healthcare organizations and how value-based programs, like Chronic Care Management, empower providers to achieve their value-based care goals.

What is value-based care?

Value-based care is an approach to healthcare that motivates providers to focus on the quality of services provided by reimbursing them based on positive patient outcomes. The emphasis on quality leads to fewer unnecessary procedures and more efficient use of resources. 

Value-based care relies on sharing patient records between providers for greater coordination, transparency, and communication with patients throughout their healthcare journey. This method prioritizes preventive measures, like regular screenings and check-ups, to detect health issues sooner, when they’re easier to manage. 

Value-based care also encourages whole-person care, including focusing on a patient’s mental health and social factors that influence their well-being. The reason for an emphasis on “value” is simple: When the quality of care improves, patient outcomes improve and costs decrease. 

Learn more: 3 Ways Providers Can Improve Care for Patients

Value-based care reimbursement

To encourage healthcare organizations to focus on high-quality care for Medicare and Medicaid beneficiaries, CMS sets quality goals that a provider must meet to receive reimbursement. In traditional fee-for-service models, providers are reimbursed for each test, procedure, or visit. 

But in value-based reimbursement, providers must successfully meet the benchmarks that demonstrate they’ve improved patient outcomes and reduced unnecessary procedures and the occurrence of preventable diseases. 

Learn more: How to add an additional revenue stream with Chronic Care Management 

How does value-based care work?

To shift the focus of your practice to value-based care, you must maintain accurate data on patient outcomes and interventions and report it to CMS. Electronic Health Records (EHRs) help you keep track of this data and coordinate patient care. 

Information from your EHR is collected and used to determine your ability to reach the CMS benchmarks for reimbursement.  

The transition to value-based care is complex and requires significant changes in how care is delivered and paid for. However, when done successfully, it has the potential to lead to dramatic improvements in patient health outcomes, cost control, and patient satisfaction. 

Your practice can leverage a variety of value-based care programs, like Chronic Care Management or Annual Wellness Visits, as you transition to value-based care. Our qualified team of clinicians helps you create care plans and assist your patients in achieving their care goals, and our quality team can help you evaluate whether you’re meeting your value-based care goals Our system also integrates with some EHRs, so you can quickly receive updates on your patients’ conditions and keep accurate records for Medicare

Fee-for-service vs. value-based care

Fee-for-service is the traditional reimbursement model that pays healthcare providers for each test, procedure, consultation, or other service they deliver. Value-based care reimbursements are driven by successful patient outcomes that result from high-quality care and efficient management. 

The shift from quantity to quality with a value-based model changes how healthcare providers are paid and how care is delivered and evaluated. The differences between fee-for-service and value-based can be summarized as: 

  • Service-based vs. outcome-oriented: The fee-for-service model bills for each service separately, and providers are paid the same amount regardless of the outcomes. The value-based care model rewards outcomes, including detecting illnesses early, reducing the number of expensive procedures, increasing patient satisfaction, and effectively managing chronic diseases. 
  • Fragmented vs. coordinated care: Fee-for-service leads to fragmented care because treatment is isolated to a provider at one time, working with only the patient information that the provider can access. The value-based model embraces integrated systems that enable providers to provide care using shared patient information.
  • Retrospective vs. prospective payments: Retrospective payments with fee-for-service pay providers after services have been delivered. Value-based care often comes with prospective payments, where providers are reimbursed in advance for expected costs for clinically defined episodes of care. Episodes could include fixed payments for a particular patient, condition, or timeframe, or they could include a lump sum to care for a patient for a set amount of time regardless of the number of visits or tests. 
  • Excessive expenses vs. data-driven decisions: In a fee-for-service program, patients’ symptoms are sometimes treated on an incident-by-incident basis, which can lead to further medical attention and excessive services and expenses. Data-driven decisions and preventive care with a value-based model can potentially decrease the duration or severity of a patient’s condition, leading to less medical intervention and minimizing costs.

Benefits of value-based care

1. Improved patient outcomes

With improved patient outcomes, patients experience a better quality of life. Patients’ chronic conditions may be better managed,  resulting in fewer doctor visits and medications. And improved patient outcomes lead to higher reimbursement. 

2. Improved access to care

Value-based models encourage patients to have a consistent source of care. Emphasis on primary care strengthens the provider-patient relationship, improves care continuity, and facilitates timely access to preventive services and early intervention.

3. Increased care coordination 

Providers who coordinate patient care are more efficient. Shared access to recent patient information, care plans, and services minimizes medical errors and redundant procedures and helps providers achieve value-based care goals.

4. Lower healthcare costs 

Avoiding unnecessary tests or treatments helps reduce healthcare expenses. And when healthcare costs are lower, patients experience lower out-of-pocket expenses. Their insurance premiums and prescription costs may also decrease. 

5. Emphasis on preventive care

With preventive care, patients can manage chronic diseases proactively, prevent more serious conditions from developing, and preemptively decrease future doctor visits. This also saves your practice time to care for additional patients and cuts avoidable expenses. 

6. Data-driven decision making

Value-based care relies on data analytics to track and analyze patient outcomes and costs. This data-driven approach enables your practice to make informed decisions, identify areas for improvement, and optimize care delivery. As you focus on achieving value-based benchmarks,  you will be rewarded for the high-quality care you provide. 

Value-based care models

Many value-based care models are used to reimburse providers for quality of care. Below are a few of the most common models developed by CMS.

1. Accountable Care Organizations (ACO)

An accountable care organization (ACO) is a network of physicians, hospitals, and other providers who agree to take responsibility for the quality and cost of care for a group of Medicare and Medicaid patients. Providers voluntarily join an ACO, selecting the one that best suits their needs. CMS offers several ACO models, including the Medicare Shared Savings Program, Advance Payment ACO Model, and Pioneer ACO Model.

ACOs have proven to reduce healthcare costs. The Medicare Shared Savings Plan saved Medicare $4.1 billion in 2020. And the benefits aren’t only financial. Collectively, ACOs had quality scores of 97.8%. CMS evaluates aspects of healthcare delivery, including patient outcomes, patient experience, and safety, using quality measures to score the quality of care delivered by providers. 

Despite these benefits, ACOs also present risks. If the ACO delivers high-quality, cost-effective care, all participating providers share the savings. However, if care quality falls short, network participants might bear the financial burden in repayments to Medicare.

2. Patient-Centered Medical Homes (PCMHs)

PCMHs coordinate patient care through a primary care physician. The PCMH model prioritizes patients’ needs and increases satisfaction by enhancing communication, coordinating care, and focusing on preventive and personalized care. The success of PCMH hinges on a quality, integrated EMR. The primary care physician will use the EMR to coordinate care with other providers as well as to report patient test results and updates. 

3. Hospital Value-Based Purchasing Program (VBP)

In this program, acute-care hospitals are reimbursed for safety, quality clinical care, efficiency, cost reduction, and positive patient experience. By achieving these performance measures, hospitals can expect fewer readmissions and procedures and increased transparency of care.

4. Merit-Based Incentive Payment System (MIPS) 

Under MIPS, providers are paid based on data that demonstrates the quality of care delivered, the level of patient engagement, the exchange of information through the EHR, and the prevalence of cost-effective care. 

When your practice participates in Chartspan’s Chronic Care Management program, you receive a consultant dedicated to improving your MIPS score and quality tracking and reporting at no additional cost. We assist your practice in following up with patients on a monthly basis and identifying gaps in care to help you achieve your quality initiatives and improve your performance scores. 

Strategies for encouraging value-based care

Transitioning to value-based care requires change, which can deter some healthcare organizations from adopting the model. CMS uses multiple strategies to encourage participation in value-based care. 

Value-based care programs 

Chronic Care Management offers many value-based programs designed to support the ongoing management of chronic conditions for Medicare beneficiaries and reimburse providers for their care. A few options include: 

1. Chronic Care Management (CCM) 

CCM programs ensure a comprehensive, coordinated approach to health management by establishing a continuous connection with chronically ill patients beyond the traditional clinical setting. Monthly communication, education about conditions and treatments, and proactive symptom monitoring help detect potential health issues early and improve patient outcomes. 

2. Transitional Care Management (TCM) 

TCM programs receive reimbursement to support beneficiaries transitioning from an inpatient hospital stay to their community setting. TCM reduces the risk of readmission and ensures a smooth transition of care. 

These services may include follow-up visits, medication reconciliation, and care coordination within 30 days of discharge.

3. Behavioral Health Integration (BHI) 

BHI programs earn reimbursement for incorporating behavioral health (mental health and substance use disorder) services into primary care settings. 

Reimbursable activities may include screening and assessment, care planning, and collaborative care management between primary care and behavioral health providers.

4. Remote Patient Monitoring (RPM) 

RPM programs earn reimbursement for the use of technology to remotely monitor and manage patients' chronic conditions. RPM services may include the collection and analysis of patient-generated health data, such as vital signs, symptoms, and medication adherence. 

Providers are compensated for the time spent reviewing and interpreting patient data, as well as for any necessary follow-up actions. Learn how ChartSpan can help you enroll patients in your RPM program

With a focus on quality and patient satisfaction, CCM programs effectively contribute to achieving value-based care benchmarks.

Financial reimbursement

Financial reimbursements compensate the clinician, hospital, or health system for performance. Reimbursements include: 

  • Prospective payments before the services are rendered to motivate providers to be more efficient with services.
  • Bundled payments, where practices receive a single payment for services provided for an entire care episode. This payment covers treatment, medications, and physician and nursing care. Reimbursement is provided collectively to all providers.
  • Shared savings models, like ACOs, that allow providers to collectively reap the benefits of delivering high-quality care and reducing healthcare costs. Learn how to maximize shared savings
  • Extra payments to hospitals that improve their performance on selected health quality measures through programs like the Hospital Readmissions Reduction Program (HRRP) and the Hospital-Acquired Condition (HAC) Reduction Program.

Financial risks also encourage providers to meet value-based care objectives. Reimbursements are tied to performance on certain quality and efficiency metrics, and this data must be collected and analyzed to receive reimbursement. 

If providers don't meet the required benchmarks, they may face financial penalties or receive lower reimbursements. Additionally, if providers exceed the lump sum provided for a care episode with bundled payments, they must bear the extra costs. 

Accreditation and regulation

Requiring accreditation and creating regulations can help standardize care and foster an environment that values high-quality care. 

CMS requires hospitals and health systems to have Joint Commission accreditation to receive Medicare or Medicaid reimbursement. Accreditation bodies set standards for high-quality care, including care coordination, patient engagement, and the use of health information technology, all of which are integral to value-based care. Accreditation also holds healthcare providers accountable to track and report on their performance in meeting quality standards. 

CMS also creates regulations that encourage providers to meet specific quality standards. For example, they require managed care plans to include a certain number of providers in their networks, affording access to Medicare and Medicaid beneficiaries. CMS also reduces payments to hospitals with excess readmissions to encourage them to focus on improving the quality of care efficiently.

Measures of success for value-based care

Value-based care relies on benchmarks or goals set by the program in which the healthcare provider is enrolled. Success is measured across several different categories, including: 

  • Timeliness of care provided 
  • Reduction of health disparities across a particular population 
  • Reduction in hospital readmissions or procedures
  • Timeliness of information shared across providers in the network
  • Patient satisfaction from surveys or reviews 
  • Percentage of patients who receive screenings or other preventive services

Providers are required to gather patient data in an EHR and report the data at determined intervals, which might be monthly, quarterly, or annually. 

Implementing a Chronic Care Management program as a solution for value-based care

A Chronic Care Management (CCM) program inherently meets the goals of value-based care for Medicare patients with chronic diseases. CCM facilitates continuity of care by maintaining connections with patients beyond the office setting. 

ChartSpan’s full-service CCM program provides your practice with a dedicated team to manage the non-clinical tasks of caring for patients with chronic conditions. Here are just a few ways ChartSpan can help your practice run a successful program: 

  • ChartSpan regularly communicates with patients and assists them in the tasks of managing chronic illness. We track and improve patient outcomes and send timely reports to your EHR.
  • Our program encourages patients to be active participants in their healthcare by educating them on their conditions and treatment options. We’ll track data and provide reports on patient engagement and satisfaction.
  • With regular check-ins and monitoring, our program can help you detect and address health issues early. Our Annual Wellness Visit software also helps you identify gaps in care from the waiting room and stay ahead of preventable health issues. 

By partnering with ChartSpan, your practice can provide ongoing care that meets the unique needs of your patients, while ensuring that your commitment to high-value care is recognized and rewarded. 

Why value-based care is a worthwhile investment

Transitioning to value-based care can significantly enhance patient outcomes, improve care coordination, and lower healthcare costs. It promotes preventive care and data-driven decision-making while ensuring that quality, not quantity, is rewarded. 

While the shift from traditional fee-for-service models may present challenges, resources like ChartSpan's Chronic Care Management program can provide the support necessary to successfully move towards value-based care. 

Contact us to learn how our CCM program and dedicated team can help your practice optimize patient outcomes to accomplish your value-based care goals.  

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