Value Based Care Challenges
Value based care (VBC) is a reimbursement model in which pay is tied to the quality of care, with the goal of enhancing efficiency of care while simultaneously improving patient outcomes. This is compared to the traditional fee-for-service model, where clinicians are paid for each service. Some of the more common value-based care systems are Accountable Care Organizations (ACOs) and Patient-Centered Medical Homes (PCMHs).
In value based care models, the care team is responsible for the patient’s overall health and well-being, and is focused on keeping the patient healthy. Interdisciplinary teams use their different perspectives and knowledge to work together and provide the best care. The hope for VBC is that it will shift the focus of healthcare to be more proactive, such as preventive care and better monitoring of health conditions; save money for everyone involved; and lead to better individual and population health.
While these are great goals to work towards, value based care organizations face some unique challenges in addition to the challenges faced by other sectors of healthcare, such as clinician burnout and shortages. Value based care clinicians monitor and coordinate care across multiple care settings, but these systems do not use the same communication tools, making collaboration difficult. As the care organizations focus on patients’ overall health, the clinicians need to effectively monitor chronic conditions, even when other health episodes arise. Many organizations get inaccurately low reimbursement, meaning they are not properly paid for the work they are doing. Value based care organizations also are leading work on social determinants of health (SDOH), but in the early stages of implementing SDOH initiatives, these organizations have to find ways to take action with SDOH data and continually manage it.
Tech can be a great resource to address these issues and push value based care programs to the forefront of medicine, with hopes of improving health for everyone. Learn more about the challenges value based care organizations face, and how tech can help.
Care Coordination Across Care Settings
Coordinating care across health settings is important for all clinicians, but it is an especially high priority for clinicians in value based care organizations, where clinicians are responsible for managing the patient’s overall health and care plan. Value based healthcare organizations may have a PCP coordinate care, or they may use a care coordinator to facilitate treatment plans among a group of clinicians. Oftentimes this person is responsible for coordinating patients’ care between all health settings, including primary outpatient visits, specialist visits, telehealth visits, acute care, post-acute care, and home health.
One of the main issues with coordinating care is the mode used to share the information. Sending patient data, especially between different EHR systems, is not easy or quick. And not all information is shared electronically. Over 60% of post-acute care facilities use phone calls to transfer patient information. Almost 75% of non-federal acute care hospitals use fax or mail to receive records from clinicians outside their system, while two-thirds of health systems send records via fax or mail. It’s frustrating to view medical records and information when they come in various modes and formats, instead of one centralized format.
Another issue is knowing who to coordinate care with and having miscommunication. If a patient goes to a hospital or urgent care, do those clinicians know the patient is part of an ACO? If not, then the ACO care coordinator or primary care provider is not involved in any treatment plans after the acute care. Additionally, poor communication can negatively impact care coordination. Communication failures contribute to up to 50-80% of sentinel events. Clinicians want to communicate, but they often lack the time and tools to easily communicate with others on their team and in different settings.
Technology can be used to help coordinate care and collaborate across the healthcare ecosystem. CareAlign’s real-time wiki allows all members of the care team to see patient notes instantly, instead of having to wait until a patient note is updated, often at the end of the day. The shared task list allows clinicians to create tasks and assign them to team members. Team members can then check off the tasks so that everyone can see what has been done and what still needs to be completed, keeping everyone on the same page.
Managing Chronic Conditions
Managing chronic care is important for VBC organizations to help give patients the best health outcomes and to manage healthcare costs and improve reimbursement. The next section will discuss reimbursement in more detail, but this section will focus on the health outcome aspect.
Six in ten adults in the U.S. have a chronic disease, with four in ten having two or more. Managing chronic conditions can be difficult because there are so many ways the diseases can impact a patients’ health, which means there are more things that a clinician has to closely monitor. For example, a patient with diabetes may take insulin or oral medication, monitor their diet, and frequently test their blood sugar. Additionally, the patient may need to see numerous specialists in addition to their PCP, such as an endocrinologist, ophthalmologist, podiatrist, nutritionist, and more. For a PCP, this is a lot of information to manage. For a care coordinator, this is a lot of people to coordinate with and ensure adequate records are sent.
Managing chronic conditions can be even trickier when acute health concerns arise. For the provider at the value-based care organization, they have to monitor the acute concern, the post-acute care, and the chronic condition(s). This can be difficult to do in 15 or 30 minute appointments, especially when the PCP doesn’t actually get that full time with the patient. This can also be tricky from the care coordination side, because now the care coordinator has to balance post-acute care appointments with specialist appointments for the chronic disease.
CareAlign’s shared task list can help clinicians ensure that care for chronic conditions doesn’t fall through the cracks. Tasks can be set with future reminders, which can help with long-term disease management. For example, a patient with diabetes may tell their PCP that they saw an ophthalmologist last month for their yearly appointment and that everything looked good. The PCP can then set a task reminder for 10 months from now to remind the patient to schedule another appointment next year.
Managing Costs and Reimbursement
Value based care organizations are reimbursed for the quality of the care they provide. While this may vary slightly, many organizations use RAF scores to get reimbursed. Risk Adjustment Factor, or RAF, scores look at patient demographics and medical conditions to predict the cost of the patient’s care each year. When a patient has an above-average RAF score, the payer reimburses more money for the patient’s expected expenses. Additionally, some organizations get to participate in shared savings, where if they meet their clinical and financial goals for their practice, they get more money.
The problem is that for many organizations, their RAF scores are inaccurately low, meaning they don’t get reimbursed fairly for the services they provide, and they are more likely to miss out on shared savings by not meeting their financial and clinical goals. Oftentimes, RAF scores are low because of incomplete documentation of patient conditions. This may occur because of workarounds, where clinicians use texts, emails, and even paper to keep track of patient notes throughout the day before entering the information into the EHR. However, because there are so many different workarounds clinicians use, they may forget to include that information in the chart or even lose the information, meaning it is never officially documented.
Technology that eliminates workarounds can improve documentation capture for more accurate reimbursement. In a pilot study at Crozer Keystone ACO, providers using CareAlign’s Care Orchestration platform saw RAF scores eight times higher with a $3800 increase in per patient reimbursement, compared to $460 for non-participating providers. This means the clinicians were getting more accurately reimbursed for all the work they were doing.
Social Determinants of Health
As value based care clinicians are responsible for patients’ overall well-being, it’s extremely important that they consider the social determinants of health (SDOH) that impact each patient. SDOH are social and environmental aspects of a person’s life that impacts their health, such as their economic stability, food stability, neighborhood, community, education, and healthcare. SDOH greatly impacts health, with estimates suggesting that up to 80% of health is determined by SDOH.
While SDOH are a huge component of patients’ health, there is often little to no room in the patient chart to identify this information (although reporting of SDOH information is changing with new CMS proposals). When a clinician sees a patient, if they can’t easily see SDOH information, will they ask about it or address it?
CareAlign’s care orchestration platform can help by allowing clinicians to view their notes uncluttered, by archiving old information so that it is not front and center on the chart, but is still available if needed. It’s easier to browse through information when there is less of it, and the clinician can focus on the relevant information instead of outdated problems. Additionally, the shared task list can serve as a space for clinicians to consistently manage SDOH initiatives. For example, a task can be set for each appointment to check on the patient’s food source and ensure they are getting enough food. This way, this SDOH information is not forgotten and clinicians can proactively address the issue to the best of their abilities.
VBC services have the potential to improve healthcare for everyone by reducing healthcare costs and improving the quality of care. While value based care organizations are still going through trials and interventions to see what works, they are making strides forward. Technology will help these organizations reach their goals for better care.