Healthcare payment models are evolving: 5 key capabilities providers need to ace the shift to value-based care

While traditional fee-for-service reimbursement models still reign supreme, more healthcare organizations are adopting value-based care (VBC) models.

Between 2019 and 2021, investment in VBC and alternative payment models  grew by 400%. During the same time period, investment in legacy care delivery models remained mostly flat.

The appeal of VBC is evident, as healthcare leaders aim to reduce costs while improving patient care and outcome quality — but implementation is far from simple. Provider organizations of all sizes are grappling with competing priorities and common challenges in data, operations, behavior change, and resources necessary for smooth, effective transitions to new care models. 

Becker's Healthcare recently spoke with Chad Dodd, vice president of product management at athenahealth, to learn why organizations must prepare for the shift to VBC, practical steps for adopting these models and where technology plays a role. 

Daily operations tend to put VBC on the back burner

For many healthcare providers, the structure, complexity and evolving nature of VBC payment models and regulations prevent them from pursuing alternatives to fee-for-service. 

"Practices often struggle to stay in touch with the rapidly changing rules governing this space in healthcare," Mr. Dodd said. "They are already dealing with resource shortages. If you combine that with the constantly evolving payment landscape, it becomes very complex for practices to move to value-based care."

Despite these challenges, Mr. Dodd said, it's important healthcare providers and leaders understand the shift toward VBC models isn't going away; data indicate it is a long-term trend and a fundamental evolution. Every year, more fee-for-service dollars are being replaced by VBC reimbursements.

"Whether you're a single doctor practice or a large practice, you may miss the speed at which the payment ecosystem is shifting," Mr. Dodd said. "Then one day, you wake up and recognize your practice is no longer financially viable for delivering care." 

Contextualized patient data at the point of care — The key to thrive in any payment model

A key enabler of VBC is extracting the right information about a patient's health history and giving providers access to it, with the right context, at the point of care. Yet, healthcare information is often highly fragmented and difficult to access across multiple care settings and payers. 

"If a patient goes to the hospital, the primary care doctor needs to know what happened and what treatments were prescribed," Mr. Dodd said. "If the patient saw a behavioral health clinician, the primary care doctor needs to know that as well, to provide the best treatments going forward." 

athenahealth's network enables clinical and financial data to flow freely between the EHR, registries, labs, pharmacies, payers and other healthcare entities. This helps to paint a more complete picture of a patient and their longitudinal record, so practices can provide the best care — regardless of the payment model.  

"Our technology simplifies healthcare by bringing insights to the point of care," Mr. Dodd said. "Providers don't have to log into the hospital system to find the patient record or log into the payer system to identify gaps in care. Time is limited and we want providers to spend their time in front of patients rather than systems. "

athenahealth also helps practices extend their staff resources through chronic care management services. Reaching out to patients in new ways improves outcomes and strengthens relationships between patients and practices.

As healthcare organizations of all sizes transition to VBC models, athenahealth's software and services help to enable smooth implementation and drive desired outcomes.

"In 2021 [the latest year for which we have data available], over 90 percent of eligible network clinicians whose data we submitted achieved exceptional performance as measured by the Merit-Based Incentive Payment System, or MIPS, which determines Medicare payment adjustments," Mr. Dodd said. He shared how Rocky Mount, N.C.-based Carolina Regional Orthopaedics leveraged athenahealth's tools and capabilities to deliver exceptional MIPS performance and earn final scores of 100 or greater (the highest possible score in MIPS).

5 core capabilities to succeed with VBC

Based on experience working with hundreds of thousands of providers who serve about a quarter of the U.S. patient population, athenahealth has identified five foundational capabilities that help practices succeed with VBC 

  1. Patient identification. Practices need to be able to identify panels of patients who need proactive assistance and additional care. With that information, practices can target outreach to those individuals to discuss the best next steps for their well-being.  

  1. Care coordination across a fragmented healthcare ecosystem. "Patients need guidance through treatments and therapies, as well as referrals to other physicians in order to best achieve their health goals," Mr. Dodd said.

  1. Well-timed care delivery. Providers need insights into care opportunities, as well as the right care pathway for patients based on their diagnoses and treatments. Having those insights at the point of care is critical for practices to be successful with VBC. "At the end of the day, value-based care is about achieving great outcomes and getting patients healthier," Mr. Dodd said. "That is best served by providers who have a relationship with and a complete picture of the patient."

  1. Patient engagement. It's essential to engage with patients in new ways by helping them achieve their health-related goals and better understand their personalized care programs. 

  1. Measurement. The importance of measuring patient outcomes can't be overlooked. "You can't improve outcomes if you don't measure them," Mr. Dodd said. "Once you've identified a panel of patients, you must determine whether they are getting healthier. Are they going to the hospital less, and can we prevent them from going to the hospital in the first place? Can we improve their overall well-being and happiness? Ultimately, that's what healthcare organizations are in business for."

Robust support in the challenging — but rewarding — shift to VBC

athenahealth works with practices in its network to help with their transition to VBC. Every transition is unique, but the common goal is to ensure all practices can remain a viable part of the community and provide the best patient care possible. 

"The transition to value-based care is a story about both large health systems and small physician-led practices," Mr. Dodd said. "We want to serve both sides of the spectrum and help everyone successfully navigate the evolving mix of fee-for-service and value-based care. "

Copyright © 2024 Becker's Healthcare. All Rights Reserved. Privacy Policy. Cookie Policy. Linking and Reprinting Policy.


Featured Whitepapers

Featured Webinars