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.
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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:
- The ability to aggregate and analyze data.
- The ability to align financial incentives between payers and providers.
- The ability to engage patients in behavior or lifestyle modifications.
- 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.
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.
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:
- Important moments in history that led to today’s current challenges.
- Why financial imperatives drive cultural change in our economic model.
- Ways MSSP can help healthcare organizations achieve financial success.
- How to utilize data to develop better healthcare delivery systems.
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:
- Machine learning
- Professional services
- Data governance
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:
- Governance that educates, engages, and energizes.
- Data transformation that addresses clinical, financial, and operational questions.
- Analytic transformation that aligns information and identifies populations.
- Payment transformation that drives long-term sustainability.
- Care transformation as a key intervention in value-based contracts.
To succeed in a value-based care environment, accountable care organizations (ACO) require a solid foundation built on five competencies of population health management: infrastructure, population evaluation, provider network, quality and safety, and waste reduction. Once the foundation is built, the healthcare organization can package this “asset” to enter into truly beneficial agreements as outlined in this groundbreaking Accountable Care Transformation Framework.
Hospitals and healthcare systems need a systematic approach and tools to demonstrate ROI from their healthcare improvement projects. Bobbi Brown, VP of Financial Engagement, shares a four-step process for demonstrating ROI: 1) define the project and business need, 2) begin to quantify ROI, 3) recruit, train and plan, and 4) evaluate costs, revenue and direct benefits. Download the Health Catalyst Clinical Improvement Financial and Executive Communications tools for estimating, calculating and communicating your ROI results.
Surviving Value-Based Purchasing in Healthcare: Connecting Your Clinical and Financial Data for the Best ROI
Reducing healthcare costs is a major driving force in bundled payments, home-centered medical care, and accountable care organizations. But each new delivery model is built on the premise of reducing revenue per patient. So how can a health system win? Find out what you can do financially survive in today’s environment.
About 40% of U.S. healthcare providers are participating in some type of shared accountability arrangement.. That means that the majority is on the sideline in a “wait and see” mode. Yet this trend will move forward, albeit in fits and starts, as purchasers and providers understand that they have oversimplified and undervalued what the other participants in the equation contribute. As the industry moves through three phases of vertical integration, fair-sighted accountable care initiatives will need to focus on at least three critical elements in designing their system for success in the steady state, including: 1) constructing the vertically integrated healthcare delivery system, 2) stratifying and allocating the risk, and 3) managing the financial risk.