Although risk-based contracts have been circulating for years, fee-for-service (FFS) still underpins the economics of care delivery. Payers, providers, healthcare executives, 还有很多人一直在问同样的问题:我们支付医疗费用的方式什么时候才能从根本上改变? The slow transition has caused many organizations to have a foot in both camps, FFS and risk-based, creating a tricky balancing act for healthcare leaders.
In this post, 我们将分享bet8网站备用企业如何在引导医疗bet8娱乐报销方式这一旷日持久的转变中发挥重要作用的观点.
Growing Momentum for Value-Based Care
虽然向基于价值的支付的过渡比CMS和支付专家所希望的要慢, value-based care has been gaining momentum the last three years, for a few different reasons:
- The increase in value-based-care-specific delivery companies, such as agilon, Aledade, and ChenMed, that intend to redefine the way care is delivered and reimbursed
- 技术进步,以实现和监测基于价值的安排和有风险的合同
- A rise in Medicare Advantage participation across the US, 随着新的和现成的市场进入者竞相在基于绩效的合同中招募尽可能多的受益人
To further convey the gravity of continued payment shifts, 考虑到CMS的目标是,到2030年,所有医疗保险FFS受益人都处于对医疗质量和总成本负责的医疗关系中.[1] Even if that goal is not fully met, 与当前状态相比,向价值的转变将对医疗保健的交付方式产生重大影响. And as we know from years of commercial market adoption, CMS payment reforms drive the rest of the market.
A Strategic Opportunity for the Physician Enterprise
In the past, 医师企业作为一种校准工具和系统利用的驱动者已经达到了它的目的, even when that meant operating at a financial loss. But it has often been overlooked as a platform for health systems to enter into, and succeed in, risk-based contracts.
For many organizations, bet8网站备用事业从初级保健bet8网站备用开始,他们提供预防和协调护理,减少高成本的护理事件. As patients move through the healthcare continuum, 初级保健由医师企业内的专业提供者补充,他们对护理结果和成本有重大影响.
一个负责任的bet8网站备用企业不再是亏本企业,而是要吸引病人并实现下游利用——它将自己重新定位为bet8网站备用向价值转型中不可或缺的一部分. This is accomplished by using all the resources of a physician enterprise, including the expertise of clinical leaders, 推动变革和重新设计护理模式,以认识以价值为基础的护理的需求.
在以ffs为中心的环境中根深蒂固的医师企业往往难以设计出一种在基于价值的护理环境中成功的运营模式. It requires integrating new workflows, rethinking clinic staffing, and effectively using technology to tie it all together—no small undertaking. 一个负责任的bet8网站备用企业必须齐心协力发展其bet8娱乐模式, which we will map out with the key levers for the operating and economic model.
Transition to Risk-Based Contracts
从FFS模式的激励和期望过渡到基于价值的合同,需要在三个关键领域进行规划和准备:提供者补偿, value-based care operations, and managed care contracting. Although the remainder of this post focuses on value-based care operations, which is at the center of care delivery redesign, 全面而成功的价值转型需要这三个领域共同努力, with leaders aligned on a common purpose and guiding strategy.
Operating and Economic Model: Key Levers
Under a value-based model, 门诊业务必须做好从偶发护理向人口健康管理过渡的准备. This transition will rely on:
- Enhanced capabilities supported by new and improved workflows that consider value.
- More robust support staff models with refined roles and responsibilities.
- Fully integrated and optimized IT, EHR, and analytical tools.
Workflows That Consider Value
诊所工作流程历来侧重于促进和获取有效的患者就诊报销, but this model will not suffice in a value-based care environment, where there are new incentives and expectations for the clinic. 工作流设计和优先级必须与每个组织基于价值的安排的特定激励相一致. These revamped workflows can include categories such as:
- New clinical tasks and actions (including documentation), which magnify wraparound care that focuses on the whole patient.
- Additional clinical monitoring, 允许提供者监测病人的健康和护理计划遵守他们不频繁的办公室访问之外.
- 患者和护理团队的沟通要求,作为一种工具来激活患者的护理并保持他们的健康.
Staffing Infrastructure
Under value-based models, 期望门诊bet8娱乐提供者及其团队支持范围更广的活动. 替代的护理团队模式将需要重新分配工作人员资源和部署全新的资源来支持增量工作, such as care gap closures and patient navigation.
是否部署这些资源取决于组织在基于价值的安排中的成熟度以及这些安排所支持的业务比例. 模型通常属于一个连续体,从完全集中到完全分散. Overall, the role of support staff tends to be elevated, 以团队为基础的护理概念对于支持基于价值的安排变得更加重要. New roles include but are not limited to:
- Health coaches.
- Care coordination team members.
- Panel management coordinators.
- Ambulatory pharmacists.
- Behavioral health professionals.
Optimized IT, EHR, and Analytical Tools
As an organization transitions to value-based care, 捕获和存储患者信息以及在临床bet8网站备用的指尖上拥有可操作数据的重要性将会扩大, because clinicians will now be at risk for their patients’ health outcomes. To remain efficient/viable, data capture must become increasingly automated, the information itself must be easy for providers and care teams to access, 人工智能/商业智能和其他分析工具的输出必须在正确的时间提供给正确的人,以采取正确的行动.
While the EHR will continue to reside at the core of the data operation, additional applications are often required to improve or achieve:
- Risk scoring and stratification.
- Care management and coordination.
- Patient engagement (to drive patients’ participation in their care).
- 自动化基于性能的活动(自动安排专业转诊),以及何时使用EHR或第三方产品.
- Predictive analytics.
一个bet8网站备用企业采取这些步骤,作为一个负责任的bet8网站备用企业运作,将成为bet8网站备用向价值转变的关键机制,并有能力赢得基于风险的合同.
What’s Next?
现在,我们已经奠定了为什么负责任的bet8网站备用企业可以成为一个成功的基于价值的护理模式的有力工具的基础, subsequent posts will discuss the key components of workflows, staffing, and optimized IT, EHR, and analytical tools in greater detail.
Is your physician enterprise prepared to provide
value-based care?
一个bet8网站备用企业采取措施作为一个负责任的bet8网站备用企业运作,将成为bet8网站备用向价值转变的关键机制,并有能力赢得基于风险的合同.
Learn MoreEdited by: Matt Maslin, Jay Santini
Footnotes
- 1.
CMMI 2021 Strategic Plan, http://innovation.cms.gov/strategic-direction.
Published March 22, 2023