Value-Based Reimbursement Transition

Concerned Doctor Value-Based Reimbursement

Value-Based Reimbursement-laying the groundwork for a transition to it is crucial.  As healthcare spending continues to rise, the Centers for Medicare & Medicaid Services (CMS) is looking for ways to get those costs under control. As such, one of the organization’s top priorities is to shift to a value-based reimbursement model as opposed to a fee-for-service reimbursement model. In the process, the goal is to put a significant emphasis on quality of care, which would urge providers to deliver the best patient care at the best value (reasonable cost) possible.


Overview of the current healthcare landscape

Value-based reimbursement is currently not the standard in healthcare. The percentage of value-based Medicare spending is around 30%. CMS is moving to achieve a 100% value-based system and hopes to reach that goal by 2025. They also expect to bring commercial and Medicaid spending to 25% by 2022 and 50% by 2025. Currently, it is around 15%.

100%   by   2025

This initiative will require participation and cooperation across the board in both the public and private sectors. In the end, it is the best way to improve patient care, especially considering that in 2019, almost 17% of people in the United States were 65 years old or older. In 2019, healthcare costs neared the $4-trillion mark and made up almost 18% of the United States economy. As the Baby Boomer and Gen X generations age into seniors, these figures are expected to rise even more.


Value-based reimbursement – critical observations

Analyze the current state of your financial situation

The transition to value-based reimbursement can be a complex one. The first area of analysis should be your financial status. By examining your financial standing prior to beginning the transition, you can offset the burden of some of the more costly systems that you may be moving away from. Making the transition can be somewhat of a risk, so ensuring that you have a healthy financial state is integral to the success of your change.

Take this an opportunity to make your organization efficient and effective like never before.  Conduct a comprehensive review and operational analysis of your clinic . . . you will likely find related critical “improvement action steps” to become a “best practices” type operation.

Do not make any sudden or drastic changes to your operations. Instead, ease your practice into the new system. Use historical data on accounting and costs prior to making the switch. This will provide a more accurate view of your finances as well as reveal how feasible and practical it is to change when you can begin the transition.

Get to know your patients

Your patient population can provide you with invaluable guidance in order to maintain a focus on quality care. Each patient population has its own needs and requires certain types of care. These needs may be related to the physician’s practice. Or, they may be conditions that are consistent with the region or even the community.

You should also identify and track patients who are high risk or those who could develop more serious illnesses as they grow older. Knowing what your patients need can go a long way in ensuring that they receive the top-quality care that they are entitled to through value-based reimbursement.

Adjust clinical operations to emphasize quality over quantity

Shifting to this new healthcare model and implementing new initiatives will require providers to make changes to how they care for patients. As a result, clinical operations may have to undergo some revisions. In some cases, it may be necessary to reconfigure your clinical operations. Or, you may choose to re-envision your clinical operations just as if you were starting it from scratch. Take this opportunity to step back and re-imagine your operations, for the better.

Integrated management teams should be part of your transition plan. These teams, comprised of physicians, administrators, and non-physician caregivers, who all come from various points of the care delivery process, can work together to improve care by setting standards for:

  • Improving care.
  • Measuring results.
  • Setting cost and quality metrics.
  • Modifying processes.
  • Managing the behavior of the provider.

Consider technology spending and investments for value-based reimbursement

As you transition to this new healthcare model, technology is likely to be one of your larger expenditures. But it is also absolutely vital. You need a strong IT infrastructure that will allow you to view feedback on quality initiatives.  Telehealth-related services are more and more offered and requested!

Investments in technology can be quite expensive. It can be a big challenge, especially when doctors try to decide on their own what kind of technology they should use. Therefore, do not be hesitant to seek guidance and assistance from outside sources.


Value-based reimbursement – next steps

Moving to a value-based reimbursement system is usually not easy, but it is not impossible either. By using a systematic approach and taking it a step at a time, you can make that transition to higher-quality care much smoother and easier.

Staying financially viable does not happen automatically.

Look to facilitators and consultants to help you make the various necessary adjustments that will get you to the point you need to be at to effectively provide your patients with the highest quality care possible at the best value.

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