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From Volume to Value: 10 Essential Strategies for Navigating the Healthcare Shift

As the transition of healthcare payment models from volume to value takes longer than expected, healthcare organizations must balance fee for service (FFS) with value-based care (VBC). The transition to VBC will accelerate, but as FFS persists and still generates adequate margins, organizations must also continue to be successful under volume-based reimbursement. Ten tools can help health systems balance VBC with FFS:

  1. A member perspective.
  2. Cautious investment in hard delivery assets.
  3. Accelerated investment in digital infrastructure.
  4. Innovative digital engagement solutions.
  5. Pricing concessions.
  6. Aligned incentives.
  7. Network management.
  8. Payer-provider trust and collaboration.
  9. Clinician and administrative alignment.
  10. Physician leadership and accountability.

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Value-Based Purchasing 2020: A 10-Year Progress Report

The year 2020 marks a decade since the passage of the Affordable Care Act in 2010 and healthcare’s first transitional steps from volume to value. The 10-year progress report is mixed. On one hand, CMS’s emphasis on quality and cost is driving an upward trend for patients and providers, with substantial improvement in readmissions; on the other hand, organizations still need to simplify and consolidate value-based programs for more widespread positive impact. As the industry enters into another decade of value, it’s time for health systems to consider the impacts of these programs so far and make sure they have the processes and tools in place to succeed in an increasingly value-driven industry.

From Volume to Value: 10 Essential Strategies for Navigating the Healthcare Shift

As the transition of healthcare payment models from volume to value takes longer than expected, healthcare organizations must balance fee for service (FFS) with value-based care (VBC). The transition to VBC will accelerate, but as FFS persists and still generates adequate margins, organizations must also continue to be successful under volume-based reimbursement. Ten tools can help health systems balance VBC with FFS:

  1. A member perspective.
  2. Cautious investment in hard delivery assets.
  3. Accelerated investment in digital infrastructure.
  4. Innovative digital engagement solutions.
  5. Pricing concessions.
  6. Aligned incentives.
  7. Network management.
  8. Payer-provider trust and collaboration.
  9. Clinician and administrative alignment.
  10. Physician leadership and accountability.

Achieving Stakeholder Engagement: A Population Health Management Imperative

To succeed in population health management (PHM), organizations must overcome barriers including information silos and limited resources. Due to the systemwide nature of these challenges, widespread stakeholder engagement is an imperative in population-based improvement. An effective PHM stakeholder engagement strategy incorporates the following:

  1. Includes as many stakeholders as possible at the beginning of the journey.
  2. Meets the unique analytics and reporting needs of the organization.
  3. Enables users to measure, and therefore manage, PHM outcomes.
  4. Provides the real-time analytics value-based care requires.

The Medicare Shared Savings Program: Four Tools for Better Profit Margins and High-Quality Care

Medicare patients make up the majority of health systems’ revenue; yet, organizations earn only a one percent profit while caring for this population. Despite historically low profit margins, Medicare can be lucrative for health systems, and through the Medicare Shared Savings Program, healthcare organizations can increase revenue with four tools:

  1. The ability to aggregate and analyze data.
  2. The ability to align financial incentives between payers and providers.
  3. The ability to engage patients in behavior or lifestyle modifications.
  4. The ability to garner support from clinicians and encourage them to lead the shift to VBC.
As the shift from fee-for-service to value-based care continues, health systems can leverage MSSP to deliver the highest level of care while also increasing profit margins.

Evolving CMS Quality Measures Move Towards More Patient-Centered Care, Less Burden for Clinicians

With today’s comprehensive Meaningful Measures initiative, CMS has refocused healthcare quality measures on improving patient needs and experiences, reducing regulatory burden on clinicians, and removing barriers to value-based payment. The evolved quality measures center on patient, clinician, and health system needs and strategic goals to truly impact improving care and lowering costs. Meaningful Measures, according to CMS, must meet seven criteria:

  1. Are patient-centered and meaningful to patients, clinicians, and providers.
  2. Address high-impact measure areas that safeguard public health.
  3. Are outcome-based where possible.
  4. Minimize the level of burden for providers.
  5. Create significant opportunity for improvement.
  6. Address measure needs for population-based payment through alternative payment models.
  7. Align across programs.

Continuity of Care Documents: Today’s Top Solution for Healthcare Interoperability Demands

While healthcare waits for the expanded data interoperability that FHIR promises, the industry needs an immediate solution for accessing and using disparate data from across the continuum of care. With FHIR potentially several years away, continuity of care documents (CCDs) are the best option for acquiring the ambulatory clinical care data health systems need to close quality gaps today. Because organizations that rely only on claims data to drive quality improvement risk missing out on more that 80 percent of patient information, CCDs are the current must-have answer to interoperability for successful quality improvement.

Healthcare’s Next Revolution: Finding Success in the Medicare Shared Savings Program

A series of revolutions has driven the development of the U.S. healthcare system, enabling dramatic improvements in all aspects of healthcare quality and outcomes over the past century. Although healthcare organizations have focused on moving towards value-based care for decades, the data shows that the shift is indeed taking place and fee-for-service models are declining. New changes to the Medicare Shared Savings Program (MSSP) will help drive this change as revisions to MSSP require ACOs to take on more financial risk earlier. This article covers the following topics:

  1. Important moments in history that led to today’s current challenges.
  2. Why financial imperatives drive cultural change in our economic model.
  3. Ways MSSP can help healthcare organizations achieve financial success.
  4. How to utilize data to develop better healthcare delivery systems.

ACOs and CINs: Past, Present, and Future

Accountable Care Organizations (ACOs) and clinically integrated networks (CINs) are two types of organizations working to address the problem of rising costs. As ACOs and CINs continue to evolve, organizations moving into value-based care (VBC) face an ever-changing landscape. This article looks at the evolution of the ACO and CIN models, what new tools ACOs employ today to promote success, and lessons learned from organizations that have succeeded in alternative payment models. It also explores what healthcare experts believe the future of alternative payment models will look like and competencies to develop to meet those changing demands.

Five Action Items to Improve HCC Coding Accuracy and Risk Adjustment With Analytics

A hot topic in healthcare right now, especially in the medical coding world is the Hierarchical Condition Category (HCC) risk adjustment model and how accurate coding affects healthcare organizations’ reimbursement. With almost one third of Medicare beneficiaries enrolled in Medicare Advantage plans, it’s more important than ever for healthcare organizations to pay attention to this model and make sure physicians are coding diagnoses appropriately to ensure fair compensation. This article walks through basics of the risk adjustment model, why coding accuracy is so important, and five action items for interdisciplinary work groups to take. They include:

  1. Having an accurate problem list.
  2. Ensuring patients are seen in each calendar year.
  3. Improving decision support and EMR optimization.
  4. Widespread education and communication.
  5. Tracking performance and identifying opportunities.

Pairing HIE Data with an Analytics Platform: Four Key Improvement Categories

Population health and value-based payment demand data from multiple sources and multiple organizations. Health systems must access information from across the continuum of care to accurately understand their patients’ healthcare needs beyond the acute-care setting (e.g., reports and results from primary care and specialists). While health system EHRs have a wealth of big-picture data about healthcare delivery (e.g., patient satisfaction, cost, and outcomes), HIEs add the clinical data (e.g., records and transactions) to round out the bigger picture of patient care, as well as the data sharing capabilities needed to disseminate the information. By pairing HIE capability with an advanced analytics platform, a health system can leverage data to improve processes in four important outcomes improvement areas:

  1. Workflow
  2. Machine learning
  3. Professional services
  4. Data governance

ACOs: Four Ways Technology Contributes to Success

With an increasing emphasis on value-based care, Accountable Care Organizations (ACOs) are here to stay. In an ACO, healthcare providers and hospitals come together with the shared goals of reducing costs and increasing patient satisfaction by providing high-quality coordinated healthcare to Medicare patients. However, many ACOs lack direction and experience difficulty understanding how to use data to improve care. Implementing a robust data analytics system to automate the process of data gathering and analysis as well as aligning data with ACO quality reporting measures. The article walks through four keys to effectively implementing technology for ACO success:

  1. Build a data repository with an analytics platform.
  2. Bring data to the point of care.
  3. Analyze claims data, identify outliers, including successes and failures.
  4. Combine clinical claims, and quality data to identify opportunities for improvement.

Social Determinants of Health: Tools to Leverage Today’s Data Imperative

Social determinants of health (SDOH) data captures impacts on patient health beyond the healthcare delivery system. Traditional health data (e.g., from healthcare encounters) only tells a portion of the patient and population health story. To understand the full spectrum of health impacts (e.g., from environment to relationship and employment status), organizations need data from their patient’s daily lives. The urgency for SDOH data is particularly strong today, as value-based payment increasingly presses health systems to raise quality and lower cost. Without fuller insight into patient health (what happens beyond healthcare encounters) organizations can’t align with community services to help patients meet needs of daily living—prerequisites for maintaining good health. Standardizing SDOH data into healthcare workflows, however, requires an informed strategy. Health systems will benefit by following a standardization protocol that includes relevant and comprehensive domains, engages patients, enables broader understanding of patient health, integrates with organizational EHRs, and is easy for clinicians to follow.

Value-Based Care: Four Key Competencies for Success

How prepared are healthcare organizations to enter into value-based care? Many may not be ready. While early value-based care adopters have focused on improving and measuring quality, they’ve often overlooked steps to bear the associated financial risk. Now that health systems can enter into alternative payment models and risk-based contracts, they need to ensure that cost is as much a priority as quality. Health systems can achieve sustainable value-based care success by optimizing the five core competencies of population health management:

  1. Governance that educates, engages, and energizes.
  2. Data transformation that addresses clinical, financial, and operational questions.
  3. Analytic transformation that aligns information and identifies populations.
  4. Payment transformation that drives long-term sustainability.
  5. Care transformation as a key intervention in value-based contracts.

DSRIP in 2018: Continuing Efforts for Medicaid Reform

As a performance-based incentive program, DSRIP (the Delivery System Reform Incentive Payment) is designed to help participating states reform Medicaid. To date, 13 states have implemented DSRIP and received a Section 1115 waiver from CMS to transform their Medicaid programs and align them with value-based reimbursement. These states have agreed to budget neutrality, transparency, statewide quality metrics, and frequent reporting of outcomes. While each state’s program structure and objectives are unique, under DSRIP, participating states share three key goals:

  1. Reducing the total medical spend.
  2. Improving patient outcomes.
  3. Establishing a direct link between provider performance and payment.

Linking Clinical and Financial Data: The Key to Real Quality and Cost Outcomes

Since accountable care took the healthcare industry by a storm in 2010, health systems have had to move from their predictable revenue streams based on volume to a model that includes quality measures. While the switch will ultimately improve both quality and cost outcomes, health systems now need the capability of tracking and analyzing the data from both clinical and financial systems. A late-binding enterprise data warehouse provides the flexible architecture that makes it possible to liberate both kinds of data to link it together to provide a full picture of trends and opportunities.

Value-Based Purchasing: Four Need-to-Know Domains for 2018

Health systems that meet the 2018 Hospital Value-Based Purchasing Program measures stand to benefit from CMS’s $1.9 billion incentive pool. Under the 2018 regulations, CMS continues to emphasize quality. To reduce the risk of penalty and vie for bonuses, it’s increasingly critical that organizations leverage data to build skills and processes that meet more demanding reimbursement measures. To thrive under value-based payment, healthcare systems must understand CMS’s four quality domains, and their associated measures, for 2018:

  1. Clinical Care
  2. Patient- and Caregiver-Centered Experience of Care/Care Coordination
  3. Efficiency and Cost Reduction
  4. Safety