It is no secret that health care reimbursement is moving from a volume-based model to a value-based paradigm. Unfortunately, this is a transformational change for which most practices are not prepared.

The Goal of Value-Based Care

Value-based care incorporates an array of clinical initiatives, delivery models, and provider payment methodologies involving bonuses and penalties. The goal is to align cost, quality and outcome measures. Participating successfully in these initiatives and models requires different capabilities and resource commitments.

Supporting Value-Based Care

The recent 2014 Survey of U.S. Physicians by Deloitte Center for Health Solutions asked physicians to rank the most important work-related resources and capabilities they needed to support value-based care. The top results were:

• Expanded clinical support capability;
• Information technology tools;
• Access to nonphysician staff;
• Access to the latest medical equipment and facilities;
• Ability to negotiate third-party payer contracts;
• Access to more patients; and
• Access to capital.

It is true that physician practices do not have control over all these elements. But, it is possible to narrow them down to a handful of critical success factors.

Success Factors

Physicians need clinical and technical support to take a balanced, end-to-end approach to delivering quality care while also competing on value. This typically takes the form of care coordination, care pathways, registry access and patient engagement tools that often are available from partners, such as hospitals, health systems and health plans.

Integrated health information technology (HIT) can enable physicians to more effectively treat patients and manage risk. Using EHR data and analytics, high-risk patients can be identified and actively managed. Physicians can test which actions/interventions best improve quality, cost, and health outcomes. HIT also allows them to communicate, share, coordinate and engage seamlessly with multiple clinicians for improved care management.

In a value-based care environment, physicians benefit from enhanced business management and organizational skills that facilitate evaluating contracts, leading care coordination activities and managing partner relationships. These can be learned through formal courses and on-the-job training.

Financial and Clinical Risks

Transparent governance structures with trusted decision-making procedures help allocate financial and clinical risks among all parties involved. If accountability standards are set for caregivers at each stage of care, physicians will feel confident of receiving credit for their contributions. Giving physicians influence over setting performance goals may help address their concerns over fairness.

Payment Models

As physicians prepare to practice more value-focused medicine, they can expect to encounter variations of four types of payment models:

1. Shared savings arrangements where a physician is rewarded if patients have better-than-average quality/cost outcomes, and penalized if they do not;
2. Per-patient-per-month capitation payments covering physician-related services, or “global” capitation payments covering costs of pharmacy, hospital and other services, as well as physician-related services;
3. Bundled payments consisting of a single payment for all the services around a particular patient’s treatment or episode of care — paid to a physician, physician group, or hospital for redistribution to individual clinicians; and
4. Fee-for-service payments combined with a monthly care coordination fee.

The Bottom Line

Work with your advisors to take a balanced, end-to-end approach to delivering quality care while also competing on value. For questions, contact Amanda Gutierrez at [email protected] or call her at 312.670.7444. Visit orba.com to learn more about our Health Care Group.