Over the last several years, providers in the United States have invested in value-based care.
Value-based care, according to Rebecca Perez, MSN, RN, CCM, senior manager of Education and Strategic Partnerships for the Case Management Society of America, can be defined as a “healthcare delivery framework that incentivizes providers to focus on the quality of care delivered instead of the volume of care delivered.”
With this model, providers are compensated based on patient outcomes, reduced disease burden, and evidence patients live a healthier life while following evidence-based guidelines.
“There are a variety of reimbursement models that require the demonstration of quality using metrics and analytics,” Perez explains. “However, some providers are challenged with the collection of metrics and analytics as they lack the needed technology.”
Incentivizing Providers
Insurers and CMS have encouraged providers and health systems to adopt value-based care to lower healthcare costs and increase competitive positioning.
“Some insurers threaten to reduce reimbursement or exclude provider networks if they do not adopt value-based care,” Perez says. “CMS has been pushing value-based care to reduce the practice of fee-for-service delivery as providers are paid for services regardless of the outcome. Providers are incentivized to order services because that’s how they are reimbursed — the more services ordered, the higher the reimbursement.”
Now, providers and health systems will be incentivized to treat patients with care and services that will provide the best possible outcome and level of patient satisfaction.
Preventing Admissions
Investing in value-based care means a greater emphasis on the primary care physician and preventing hospital admissions and readmissions.
“The literature demonstrates that health outcomes improve when a patient has a trusted relationship with a primary care provider,” Perez notes. “At the primary care level of care, patients receive preventive care and chronic care management. A focus on outpatient management of conditions and prevention measures will result in fewer hospitalizations and the need for expensive levels of care like admissions and readmissions.”
Sound Physicians notes “even the most successful value-based care organizations will still have hospital admission rates of anywhere from 100 to 200 admits per thousand members. With 50% of Medicare spending happening in the acute episode of care that is initiated by that admission, a holistic approach to cost and quality must look beyond primary care interventions to the other major drivers of cost and quality.”1
What does the “holistic approach” look like?
According to Perez, it means care is coordinated across the continuum and includes not just physical illness, but also social determinants of health and mental and behavioral conditions.
“Physical illness is complicated by the presence of social and psychological barriers,” she explains. “These barriers must be addressed equally with physical illness. In fact, they may be the priority over physical illness because disease burden may not be impacted unless the patient has social and psychological stability.”
Caring for the whole person is becoming more and more important, too, as life expectancy in the United States continues to increase, with many people living longer with chronic conditions.
Caring for Medicare Population
As the country’s population trends older, the Medicare population is larger as well — and chronic, long-term illness becomes more common.
Case managers and care coordinators may need to focus on ways to better manage Medicare spend while also enhancing patient care.
One thing to keep in mind, Perez notes, is “Medicare beneficiaries with chronic conditions utilize the majority of healthcare resources with admissions, readmissions, skilled facility placement, polypharmacy, and other, more expensive outpatient services.”
Properly navigating the case management process for this population reduces costs and makes a difference in patient care overall.
“The case management process begins with an assessment for challenges in illness management, social, and psychological, then a plan of care is developed to address any challenges and mitigate risk,” Perez explains. “Supporting Medicare beneficiaries to develop a trusted relationship with their primary care provider and supporting outpatient management of their conditions will reduce admissions. Not all admissions will be prevented, but with effective transition management and care coordination, case managers can implement a plan to prevent readmissions. Transition management and care coordination are foundational case management activities that will result in improved outcomes and patient satisfaction.”
Regardless of payer, case managers can help boost patient care across the board, Perez says, because “care coordination is an important activity for quality patient care and a foundational function of case management: providing the right care at the right time for the right person.”
As case managers work with patients to support primary care provider relationships, advocate for needed care, and educate patients to learn self-management, patient care overall will be enhanced regardless of the healthcare setting or payer, Perez adds.
REFERENCE
- Bessler R. How to better manage your Medicare spend to boost patient care. Becker’s Hospital Review. Dec. 7, 2021.
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