Embracing Patient-Centric Care: The Rising Impact on Specialized Medicine
The CMS introduced its first value-based program, End-Stage Renal Disease Quality Incentive Program (ESRD QIP), in 2008. Since then, the number of value-based models introduced by the CMS and other healthcare innovators has expanded dramatically. There are now no fewer than 94 value-based innovation programs launched by the CMS alone, with variations and other models piloted or employed by various payers, consortiums, and advocacy groups also in play across the healthcare industry.
Value-based care (VBC) and reimbursement models have been at the forefront of industry discussions, activity, and business ventures for the past 15 years, bringing the concept of value over volume—that is, quality outcomes and cost-efficiency of care delivery vs. free for service—into sharp relief.
Value is defined as the ratio of quality over cost, and should translate into a better patient experience and reduced per capita health expenditures. One of the most successful value-based models among primary care providers (PCPs) is the ACO, or Accountable Care Organization.
ACOs are groups of doctors, hospitals, and other healthcare providers who work together to coordinate care for their patients. They do this by sharing information, developing care plans, and providing preventive care. They’re paid based on the quality and cost of care they provide. If they can provide high-quality care at a lower cost than they would have under traditional fee-for-service Medicare, they can share in the savings.
The Affordable Care Act (ACA) introduced the Medicare Shared Savings Program (MSSP) in 2010, a voluntary program that allows ACOs to share in the savings they achieve by providing high-quality, coordinated care to Medicare patients. ACOs have the potential to improve the quality of care and lower costs for Medicare beneficiaries. While the ACO is a relatively new model, they’ve grown rapidly in recent years. Since 2010, more than 1,200 organizations have held an ACO contract in Medicare, Medicaid, or the commercial sector, and have served tens of millions of patients.
ACOs prioritize preventative care for long-term health and wellness over frequent, episodic care. A greater focus on VBC in the primary care setting was designed to drive fewer referrals and a wiser utilization of healthcare dollars. The CMMI (CMS’s Center for Medicare and Medicaid Innovation, a-k-a the CMS Innovation Center) has been experimenting with various Alternative Payment Models (APMs) that aim to bring the concept of value to primary care, such as the ACO and ACO Realizing Equity, Access, and Community Health (ACO REACH).
These models, however, did not incentivize involvement of specialist physicians who provide services beyond the scope of PCPs’ offices. Consequently, there was a clear absence of clinical and financial alignment between primary physicians and specialists. Specialty care providers were being incentivized for episodic payments, and this led to ineffective referral management, lack of coordination, and dysfunction among members of the care teams. And that resulted in an inability to realize optimal specialty care.
The good news: The CMMI has now developed a strategy to harmonize and enhance care coordination between primary and specialty care practices to achieve true accountable care for patients. They’ve introduced several innovative payment models for specialty areas, such as:
All of these programs are designed to incentivize high value, cost-efficient specialty care to improve patients’ quality of life.
Specialty practices have traditionally been engaged in providing episodic care to patients whose attribution and, therefore, overall total cost of care risk was assumed by their primary care physicians and practices. With the introduction of value-based payment models for specialties, this scenario is changing, bringing with it novel opportunities for specialists as well as new challenges.
The shift to value-based specialty care has a huge potential to improve care quality and clinical outcomes by enhancing the coordination between primary and specialty care providers, and holding specialists accountable to care and outcome quality. It will also incentivize specialists to manage the cost of specialty care, leading to more affordable and cost-effective care—especially for patients living with multiple chronic conditions and comorbidities, where advances in treatment, and their costs, might be outpacing benefits.
But shifting to risk-sharing in specialty practices is no simple feat. As with primary practices, specialists will encounter various challenges specific to their specialty, stemming from their unique clinical workflows. To harness the clinical and financial benefits of value-based transformation, specialty providers must prioritize technological enablement, just as primary practices have learned to do.
Data readiness is imperative to help specialty practices make sense of patient data, and gain visibility into their contract performance, physician efficiency, cost drivers, and patient behavior. The four pillars of digital enablement and capability building which specialists should focus on are data interoperability, joint attribution, care management workflows, and patient engagement. Let’s drill into each of these pillars.
With the rising need for specialist practices to become technology-enabled, speciality care providers need an end-to-end data and technology partner who can provide a strong data foundation for them, enable interoperability between primary and specialty practices, and have advanced analytical capabilities which can uniquely cater to each specialty’s needs.
A versatile platform which effectively unifies patient data across physician locations, EHR formats, claims, and laboratories to create a 360-degree longitudinal patient record is the starting point for the digital revolution of speciality care. This single source of truth powers advanced analytics, clinical decision support, care management, and patient engagement to enable patient-centric, high-quality, cost-efficient care.
Cloud-based population health management solutions allow practices to leverage unified patient data for precise risk adjustment, capturing potential codes at the point of care. These solutions identify cost drivers, evaluate physician performance, and develop tailored care management protocols to support patients throughout the care continuum. They also facilitate patient outreach across various communication channels, promoting compliance, enhancing staff efficiency with smart automation, reducing administrative burden, and integrating a robust health equity strategy into care delivery.
These advanced technologies will enable specialty practices to obtain valuable insights on quality and cost-of-care metrics, supporting enhanced clinical outcomes and optimal performance in risk-based reimbursement models. And partnering with a true healthcare technology leader can accelerate value-based care transformation and upscaling of specialty practices.
Learn how Innovaccer’s Data Activation Platform and Population Health Management solution suite has helped support value-based transitions for large specialty organizations. Book a demo with our team of experts to find out more.