The essence of Value-Based Care

That healthcare is changing at a fast pace is a reality all the stakeholders are coming to terms with. Irrespective of their preferences, they are left without a choice but to adapt. The transition taking place is evolving it from being proficiency-based art to a data-driven science. Physicians are shifting from being freelancers to being employed by hospitals. The delivery methods are changing from being one-size-fits-all community hospitals to vast hospital networks which are organized around centers of excellence. There is however, a certain level of criticism from the provider community towards this demand for change – almost to the extent of being reluctant to accept it. This could well be the result of their realization that the shift will finally result in better care outcomes for patient and less inflow of money for them. This is where the fraternity needs to take a step back and look at what lies at the core of their profession – that of helping people overcome their health related ailments. One cannot deny the fact that the profession has a certain degree of nobility attached to it. As much as it is important for physicians to gain financially, the overriding factor which draws people to take up this profession is expected to be a deep desire to serve humanity by curing people of their health related problems. Infact the ones who have realized it and connect to it are eagerly looking forward to days where they would have satisfied patients with lower expenses and they would be proud of their work. The tension which now exists between patients and physicians does not please the majority of the people in the profession and they would expect the new model to give way to trust and happiness for the providers. This is not to say that physicians are expected to lead lives of monks with no desire to gain financially from their services but to let money play the most important role in the system would be going against the core tenets of the profession.

In order to emphasize on this shift in focus from a volume to a value based care, the Centers for Medicare & Medicaid Services (CMS) incorporated value-based purchasing rules which tied acute care Medicare reimbursement of hospitals to quality performance starting in the year 2012. To give this approach a push, 1% of the payments under Medicare for 2012 was put aside and later given away as bonuses to those hospitals which scored above a certain score in some identified measures. Patient satisfaction was the determining factor for about 30% of the incentive payments while the rest 70% was based upon improved clinical outcomes. Noticing the positive difference the approach brought about, a further modification was brought in that resulted in enhancing the payment under the hospital value-based purchasing program (VBP) starting October of 2013. As per the new rule, there was an increase in the payment rates to general acute care hospitals by 0.9 percent, after allowing for other payment and regulatory changes. Although it was suppose to result in increasing the Medicare spending by approximately 175 million, its real benefit was the thrust it was expected to provide towards the adoption of a value based model. There are also penalties in place for hospitals for excess readmission for certain ailments like heart attack, heart failure and pneumonia unless they are planned ones. Also, moving forward there are likely to be more such rules in place to penalize hospitals for conditions acquired during the course of treatment. These steps are intended to bring about more focus towards infection control and prevention.

As much as the reasons appear compelling for moving to a value-based model, early experiments have shown mixed results. The success of value-based approach is hinged on making everything measurable and quantifiable and this is precisely where the hurdles start. Each patient is unique and so the impact of the same disease on a population is not going to be similar. With some patients, things might get a bit more complex resulting in higher expenses. Regardless of whatever incentives are created to make it move faster, a complete shift to this new model will take time. This is going to be driven primarily by the need to bring about some changes in the overall setup. For instance, it has to first and foremost start with getting the buy-in from physicians who are willing to embrace this approach. Furthermore, a successful transition from volume to value will require investment in advanced analytics and clinical information to evaluate performance data, as well as holding all stakeholders - clinicians, staff and patients, accountable for quality improvements.

We provide healthcare application testing & healthcare software development services. If you would like to speak to one of our certified software developers, please reach out to us at Mindfire Solutions.

Concierge Medical Care System

Some of the Health policy makers in the US feel that the current system is highly expensive and is not producing the desired effect in terms of outcomes. Their belief is based on a trend which is seeing a lot of physicians opting out of insurance-driven traditional model and shifting to a concierge medical care model. This is primarily the result of high administrative costs and below expectation payout by insurance companies. In fact some are struggling to stay afloat because of this. This has resulted in quite a number of Physicians moving to a Concierge Medical Service model. Also, Patients assigned to Primary Care Physicians have to wait for hours and days before being able to get an appointment, that too for short time durations, with them. Concierge system of providing medical care is one in which a patient pays an annual fee or retainer to a primary care physician. Depending upon the agreement there may or may not be some additional amount charged.

This can come as a relief for people who have had to wait for weeks to see the doctor. For some additional fees, patients get the opportunity to enjoy same-day appointments with 24-hour access, get more time with the doctor and invest in extra preventative care. Although the broad factors remain the same, variants exist in terms of payment requirements, operation and structure. In this, the insurance companies are completely taken out of the loop and patients pay for the service that is rendered. Currently, the most common type of Concierge model in practice has physicians holding on to their traditional practice but charging an additional fees from a small group of patients who are then entitled to special treatment and services which are not otherwise covered by traditional insurance. The variant at the other extreme has the physicians cancelling relationships with Medicare, Medicaid and insurance carriers. They build their practices aimed exclusively for patients willing to pay a retainer fees. The amount paid as retainer depends entirely on the range of services a particular patient wants to cover. Generally these patients carry insurance cover for all those types of services which are unavailable with their concierge physicians.

It enables physicians to focus more on their patients, spend more time on them rather than having to deal with the payment issues which generally arise out of handling insurance companies. Also, the physicians are absolved of being influenced by the insurance companies changing their ways of practice or suggesting what drugs to suggest, etc. They now have to decide on the number of patients they would like to attend to and do everything they possibly can to provide them with the best of care. The patients on their part however are responsible for prescription drugs and other ancillary medical devices and testing. Patients are required to use their insurance to pay for visits to specialists and hospitals. Many feel that this approach is going to lead to a two-tiered health-care system - one in which the rich will get preference for care over the ones who are not financially at par. There is also another problem likely to arise. Because of the inherent nature of the model, physicians will be required to reduce the number of patients they can handle which over a period of time, if the system gets widely accepted, will lead to a dearth of primary care physicians.

Besides this, Affordable Care Act will compel approximately 30 more million people to be insured. This again will lead to a demand for PCPs. So there is a high possibility of the overall healthcare system taking a hit because it widespread use of concierge practice will mean that more and more people, esp. with lower income levels, will be left without any access to primary care. Presently, the number of physicians who have chosen to adopt this new model is very low. For the model to succeed it has to be gain acceptance from a bigger and wider audience. There are some physicians who are moving to a model with the intent of directing their focus is entirely towards wealthy patients. Besides visiting them at their homes they also accompany them to the specialists.

In all such situations, online applications which impart healthcare services or at least assist the physicians in servicing patients are picking up steam. Needless to say, healthcare software testing also has to be done to ensure the effectiveness of the systems are maintained.

We provide healthcare software development services. If you would like to know more about our expertise in healthcare software maintenance, please visit us at Mindfire Solutions.