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Activation Pathway: Total Cost of Care

Problem context: cost performance under risk depends on patients completing the right care at the right site. Also searched as: total cost of care, TCOC, medical cost trend.

The Impact of Managed Care on Value-Based Healthcare

The Impact of Managed Care on Value-Based Healthcare

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A managed care organization (MCO) can add to the success of value-based care. Healthcare facilities are adopting MCOs to improve their patient outcomes while controlling the costs. What managed care organizations do in value-based care is use preventive health, population health management, and care coordination to manage patient care. They also coordinate between the various payers—including Medicare, Medicaid, and private employers—to provide comprehensive healthcare services. By focusing on patients with chronic or complicated conditions, MCOs help to reduce unnecessary medical expenses and improve overall health outcomes.

Value-Based Care Models

In value-based care models, healthcare providers are incentivized by the payers to achieve specific health outcomes. The Bundled Payments for Care Improvement (BPCI) Advanced is a program that does just that. Payers can manage how payments are made and decide who is in their network. That helps to ensure cost-effective and high-quality care. This model highly encourages providers to focus on their patient outcomes rather than the number of services (pap smears, vaccinations, CT scans, etc.) that they provide in their practice each week.

Read more: Differences Between Fee-For-Service and Value-Based Care Models

Managed Care Plans—HMOs and More

Managed care plans come in different forms. These include HMO, PPO, Point of Service (POS), and Exclusive Provider Organization (EPO) plans. Each plan offers varying levels of flexibility and cost management. They are best tailored to meet the needs of different patient populations.

Not Just Focused on Payment

The role of managed care in value-based care does more than focus on payments. MCOs invest in technologies and data analytics to track patient outcomes and identify areas that need improvement in healthcare facilities. This proactive approach helps in managing the health of various populations. Consequently, patients receive the right care at the right time. This can be quite beneficial to struggling populations that have fewer doctors or facilities.

Meeting the Metrics

How does it work? The BPCI Advanced program rewards providers for meeting specific patient outcomes. This creates a financial incentive for providers to deliver high-quality care while keeping the expenses reasonable. Payers, including both public and private, collaborate with managed care organizations to create value-based care models. They ensure that providers have the resources and incentives necessary to then achieve better health outcomes for their patients.

Bringing the Payer, Provider, and Patients Together

Ultimately, managed care organizations are essential to transition from the past flawed systems to value-based care. They bring together payers, providers, and patients to create a healthcare system that prioritizes quality and efficiency. This not only improves patient outcomes but reduces healthcare costs at the same time.

For more information on managed care in value-based care models, consult our experts at Guideway Care. Let us work with you to implement proven systems like BPCI Advanced and enhance the overall patient experience.

In conclusion, managed care has become a critical driver in advancing value-based healthcare, offering improved patient outcomes and cost efficiencies through coordinated efforts. By leveraging innovative solutions and fostering collaboration among hospitals and health systems, oncology practices, risk-bearing entities, payers, bundle participants, and behavioral health providers, the healthcare industry can continue to thrive in delivering comprehensive, patient-centric care. As the landscape evolves, embracing these changes ensures a sustainable, value-driven approach to meet the growing demands of modern healthcare systems.

Essential Strategies to Enhance and Implement Value-Based Care

Essential Strategies to Enhance and Implement Value-Based Care

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Value-based care (VBC) is a revolutionary provider payment model that rewards high-quality healthcare rather than the quantity of services provided. VBC and other advanced payment models, like Bundled Payments for Care Improvement (BPCI), aim to improve patient outcomes while reducing healthcare costs. Here are key strategies to implement value-based care effectively in your practice.

Identifying High-Risk Patients

One of the main strategies to implement value-based care is identifying patients with the highest risk. These patients usually have chronic conditions or multiple health issues that require frequent medical attention. Using data analytics and risk classification tools, healthcare providers can pinpoint these individuals and prioritize their care. Early identification allows for proactive management of their conditions, reducing hospital admissions and improving overall health outcomes.

Addressing Patients With Immediate Care Needs

After identifying high-risk patients, addressing those needing immediate care is essential. This involves creating personalized care plans tailored to their specific health needs. Healthcare professionals can prevent minor health issues from worsening by focusing on timely interventions and continuous monitoring. This helps to improve patient outcomes and reduce healthcare costs. Coordinated care teams, including primary care physicians, specialists, and case managers, are vital in delivering comprehensive and efficient care to these patients.

Promoting Annual Wellness Visits

Another value-based healthcare strategy is encouraging patients to attend annual wellness visits. These visits allow healthcare providers to conduct preventive screenings, update vaccinations, and review patients’ overall health status. Regular wellness visits help in the early detection of potential health issues, allowing for timely interventions. They also foster a strong patient-provider relationship, enhancing patient engagement and adherence to care plans.

Maintaining Open Communication With Provider-Relation Representatives

Value-based care strategies also entail effective communication with provider-relation representatives. This is crucial as representatives are liaisons between healthcare providers and payers, navigating the complexities of VBC contracts and performance metrics. In addition, keeping open lines of communication ensures that providers are well-informed about the requirements and expectations of VBC programs. This ultimately improves the quality of care patients receive.

Implementing and improving value-based care requires a multifaceted approach that prioritizes patient-centered strategies. By implementing value-based care strategies, healthcare providers can achieve the primary goal of enhancing patient outcomes while reducing the cost of care. Contact Guideway Care and schedule a consultation with our experts to implement these strategies successfully and improve the quality of healthcare and the overall sustainability of the healthcare system.

Understanding the Key Differences Between Fee-For-Service and Value-Based Care Models

Understanding the Key Differences Between Fee-For-Service and Value-Based Care Models

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In the healthcare industry, two main payment models have emerged: fee-for-service vs value-based care. As healthcare providers and patients navigate these two approaches, it’s important to understand their distinctions and how they impact the quality and cost of care.

Fee-For-Service: Paying for Quantity

Under the traditional fee-for-servicemodel, healthcare providers are reimbursed for each individual service they perform. The more procedures, tests, and treatments a provider delivers, the higher their payment. While this fee-for-service structure offers transparency in billing, it has some notable drawbacks:

  • Incentivizes quantity over quality
  • Can lead to unnecessary tests and procedures
  • May result in higher costs for patients
  • Lacks focus on patient outcomes and care coordination

This fee-for-service approach, while straightforward, may not always align with delivering the most effective and efficient care for patients.

Value-Based Care: Prioritizing Quality Outcomes

In contrast, the value-based care modelprioritizes the quality of care over the quantity of services provided. Under this model, healthcare providers are rewarded for achieving positive patient outcomes and delivering high-quality, coordinated care. The value-based healthcare approach offers several advantages when compared to fee-for-service:

  • Encourages providers to focus on prevention and patient well-being
  • Promotes collaboration among healthcare teams
  • Can lower healthcare costs by reducing unnecessary services
  • Emphasizes data-driven decision-making to improve care quality

By shifting the focus from volume to value, this model aims to deliver better care experiences and outcomes for patients.

Navigating the Transition

As healthcare systems recognize the benefits of value-based oncology care and care across all medical specialties, many are working to transition away from fee-for-service to value-based care models. However, this shift requires significant changes in how providers operate and get paid. To successfully navigate this transition, healthcare organizations must:

  • Invest in robust health IT systems to track and analyze patient data
  • Foster a culture of continuous quality improvement
  • Educate staff on new payment models and performance metrics
  • Collaborate with payers to develop value-based contracts
  • Engage patients in their care and gather their feedback

While change can be challenging, embracing value-based care over fee-for-service models offers an opportunity to transform healthcare delivery for the better.

Partner With Guideway Care for Value-Based Care Success

Guideway Care understands the complexities of transitioning to value-based care. Our healthcare navigation solutions help oncology practices succeed in this new landscape by providing personalized patient support, care coordination, and data analytics. With our expertise and technology, we can help your practice deliver high-quality, patient-centered care while thriving under value-based payment models. Contact us today to learn more about our services and how we can support your value-based care success.

What is BPCI?

What is BPCI (Bundled Payments for Care Improvement)?

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Bundled Payments for Care Improvement (BPCI) was an initiative created by the Center for Medicare and Medicaid Innovation (CMMI) to test the efficacy of several different episode-based payment models in producing higher quality, more coordinated health care at a lower cost to Medicare. BPCI was launched in 2013 concluded in 2018. The BPCI Advanced Model is a new iteration of the program and a continuation of efforts to implement episode-based payment models, also referred to as bundled payments.

Bundled Payments and BPCI

In traditional fee-for-service (FFS) payment models, providers are paid for each individual service they furnish to patients for a single illness or course of treatment. Bundled payments provide a single, comprehensive payment that covers all services provided during a patient’s episode of care (services provided to a beneficiary with a medical condition within a specific time frame and across the continuum of care). Medicare has been working towards reducing healthcare costs through episode-based payments for more than three decades, beginning with the introduction of the inpatient prospective payment system (IPPS) in 1983. BPCI was the most ambitious and wide-ranging bundled payment initiative CMS had ever attempted, and included hospitals, physician groups, post-acute facilities, and more. BPCI participants could choose from one of four models, and three of the four models gave participants the ability to further specify which of 48 different clinical episodes they would include. Each of the four BPCI models had important differences in which portions of the continuum of care were included, as well as in how payments were made and discounts calculated. Specifically, each model varied in:
  • Eligible participants
  • Clinical conditions included
  • Included services (various combinations of inpatient, post-acute, and readmissions)
  • Expected discount
  • The method for provider payments
  • Quality measures used

Was the Initiative Effective?

The overarching goal of bundled payment models, including BPCI, is to reduce the cost of care while preserving or improving outcomes. There is clear evidence that BPCI participants that included surgical procedures in their bundle have achieved both cost and quality improvements, but more progress needs to be made in bundles focused on chronic conditions. Timing may be an issue, as hospitalizations correlate well as the beginning of a surgery-involved episode, but are unlikely to align with the onset of a chronic medical condition. In order to thrive under bundles for chronic conditions, hospitals will have to take a more proactive approach and tackle non-clinical issues that feed into chronic conditions, including social determinants, though most currently lack the mechanisms to do so.

BPCI Advanced

The Bundled Payments for Care Improvement Advanced (BPCI Advanced) Model is the new iteration of BPCI. The new model aims to build on the successes of BPCI, while making modifications to correct deficiencies in the old program. Some key differences include:
  • A wider view of the episode of care – the duration of all clinical episodes now includes the anchor stay + 90 days, while the original BPCI program allowed participants to choose from 30- 60- or 90-day bundles.
  • There is a higher element of risk, with the following elements all playing a role:
    • Fewer exclusions are allowed – all Part A services resulting from the Anchor Stay/Procedure are be included, as well as post-acute services, including home and hospice care. Participants must expand their cost and quality efforts to include services previously excluded from the bundle.
    • Up to 10% of payments are at risk for quality performance – this differs from the original program, which had no quality component.
    • Downside financial risk will take effect immediately – the phase-in period utilized in the original program is not part of BPCI Advanced.
    • Outliers are more narrowly defined as the 1st and 99th percentile – the original program allowed three tracks (1st and 999th, 5th and 95th, or 5th and 75th) for determining which patients episodes would be capped before inclusion in cost calculations, based on their status as an outlier.
  • Changes to align with other quality programs, prevent overlap, and incentivize physician group practices (PGPs):
    • BPCI Advanced will qualify as an Advanced Alternative Payment Model (Advanced APM) through the Medicare Access and CHIP Reauthorization Act (MACRA) – this could incentivize physician group practices and hospital-employed physicians to participate in order to avoid payment adjustments under the Merit-based Incentive Payment System (MIPS).
    • Next Generation or Track 3 MSSP ACOs are excluded – participants in these and other APMs will need to be aware of the rules regarding how and when various payment models may be implemented.
    • Hospitals could lose episodes to PGPs – in the original BPCI program PGPs were in the minority, and were at a disadvantage if they joined in Phase II as opposed to Phase 1. Under BPCI Advanced, PGPs will always take precedence.
The opportunities presented by BPCI Advanced will allow participants to progress in terms of value-based care, but will also present increased risk and less flexibility than the original program. It remains to be seen whether the updates to the BPCI model will produce additional benefits, but it’s clear that CMS will continue to drive towards value-based care with episode-based reimbursement models.

Additional resources:

Non-clinical care guidance reduces unnecessary utilization while improving patient satisfaction. Request Contact for more information about how Guideway Care can help your organization succeed in bundles today.

What’s Up With CMS’ Cardiac and CJR Bundled Payment Delays?

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An Overview of Facts and Opinions About CMS Delays for Cardiac and CJR Bundled Payments from Leading Healthcare Voices

Yesterday, healthcare news and blog outlets were virtually tripping over each other to announce the Centers for Medicare & Medicaid Services’ decision to delay two bundled payment program deadlines. CMS’ first delay relates to Cardiac Care. In short, CMS changed the original July 1, 2017 effective date for mandatory bundled payment programs for heart attacks and bypass surgeries to October 1, 2017.
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The second relates to Comprehensive Care for Joint Replacement, a topic that we’ve been discussing for months—including a recent blog, “Bundled Payments and CJR Among Key Topics of Interest at ACPM’s 2017 Orthopedic Value Based Care Conference.” CMS is delaying the expansion of the CJR bundled payment program from the original July 1, 2017 date to October 1, 2017. If that explains the “what” and “when” factual reasons for the delay, what about “why”? CMS’ announcement explains it is to:

• Extend review time

• Potentially modify the policy

• Ensure participants understand the policy

However, there is much more being said about the delays, especially from the aforementioned healthcare news and blog outlets that have cast some compelling analyses. For instance, Healthcare DIVE.com speculated “the recently released interim rule casts doubt on the future of bundled payment initiatives,” even after President Donald Trump’s February 2017 executive order to delay the new rules. The reason for the sudden doubt is that, according to the American Journal of Managed Care:
“…even if the coverage elements of the Affordable Care Act (ACA) are repealed, payment reform would move forward under the Trump administration, in part because Republicans voted overwhelming with Democrats for the Medicare Access and CHIP Reauthorization Act (MACRA).”
The delays are also possibly having real-time impacts for healthcare providers not expecting delays, much less potential rollback of the programs. As Managed Health Care Connect.com suggested:
“Although CMS originally envisioned the bundled-payment programs would help clinicians accrue incentives under the Alternative Payment Model, delays may have implications for providers who were hoping to use the bundled payment models during their MACRA verification.”
In sum, the confusion about the health of current and proposed CMS programs—especially those closely tied to the Affordable Care Act—is and was to be expected, which we touched in at the beginning of the year in our blog, “How Might Repealing Obamacare Affect Medicare Reimbursements?.” And, as stated in that blog, the best advice is perhaps to “do what you can now to ensure the best outcomes for your Medicare patients, which can be improved with a reliable and efficient patient management system.”
Derek Rudnak is a freelance healthcare marketing content creator that frequently contributes exclusive blogs to Guideway Care.

Three Key Metrics To Control Post-Acute Care Costs And Optimize CJR Reimbursements

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After spending last weekend with a group of clinicians, administrators and healthcare executives at the Interdisciplinary Conference on Orthopedic Value-Based Care, one thing is clear: Bundled payments implemented by Medicare’s Comprehensive Joint Replacement program are shaking up the foundation of how every stakeholder must address joint replacement therapy. The Comprehensive Joint Replacement Program represents much more than reimbursement reform — value-based care is transforming how healthcare is delivered, leaving many wondering how to best position themselves to maximize revenue and mitigate risk. With so many stakeholders involved, it seems extremely complicated to identify and manage the drivers of expenses that CJR seeks to control. The first step to a sound bundled payment strategy begins with an examination of current processes and realignment to create a multi-disciplinary and team-based system of coordinated care that is centered around the patient.  Then, the data shows that most of the variation in episode costs, and thus the opportunity for improvement, can be tracked to post-acute care (PAC) utilization. Optimizing this portion of the episode is a key focal point for hospitals operating under CJR regulations, and tracking metrics associated with this recovery period is core to any successful CJR strategy. There are three important metrics related to PAC that should be analyzed to help identify and eliminate the barriers to maintaining healthy margins when subject to bundled payments for joint replacements.
  1. Percentage of patients discharged directly to their homes – It’s fairly obvious that patients discharged to private homes cost much less than those that require institutional post-acute care, so tracking that data is imperative.  As a rule of thumb, hospitals that discharge 50 percent or more of joint replacement patients to their homes are healthy programs. Increasing this metric over time will require coordination with all stakeholders.  Dashboards are effective tools to tracking this important driver of success.
  2. Length of stay in institutional facilities – PAC spending accounts for 44 percent of total episode costs for knee replacements, and length of stay in skilled nursing facilities (SNF) is the largest driver of that cost. Tracking this metric in the aggregate is important, but also examine average length of stay by facility, particularly for your largest volume SNF’s, and look for variations.  This data will help you make informed decisions about your network and engage with your partners to reduce unnecessary costs.
  3. Hospital readmission rates – Hospital readmission rates vary considerably among diagnoses, and knee replacement surgery is fortunate to enjoy low rates with an average of only 7 percent.  Targeting a readmission rate of 5 percent or less is a worthy goal.  However, you need to also examine the costs of your readmissions, which is available in the data the Centers for Medicare & Medicaid Services provide to CJR hospitals.  It is possible to have a low readmission rate, but high readmission costs due to catastrophic readmissions.  Parsing the data on readmission rates and costs will help pinpoint issues that you can then go tackle.
With the five year long trial of Comprehensive Joint Replacement Program bundled payments not even a year old and uncertainty surrounding the future of healthcare policy with the newly elected administration, many healthcare providers have not begun learning how to best comply with these changes.  As of now, CMS remains committed to using alternative payments for 50 percent of all Medicare reimbursement by next year, and most hospital leaders believe value-based care is here to stay. It makes sense to begin planning for this eventuality because it involves redesigning processes and care delivery, and results in better outcomes and a better patient experience. At Guideway Care, we believe that simple low-cost technology solutions that provide real-time insight into how patients are recovering from surgery are beneficial to all healthcare providers, whether they are working within CJR requirements or simply dedicated to providing the highest quality care and reducing expenses. Let us show you how you can increase patient satisfaction, lower costs, and position for value-based care changes associated with Comprehensive Joint Replacement program.

BPCI Initiative Year 2 Lessons Learned

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Top Results from CMS’ Bundled Payments for Care Improvement Initiative Progress Report

The Centers for Medicare and Medicaid recently published CMS Bundled Payments for Care Improvement Initiative Models 2-4: Year 2 Evaluation & Monitoring Annual Report. If you have been following the recent developments of either the BPCI initiative or the Comprehensive Care for Joint Replacement mode (CJR), you are likely aware of their functions and similarities. If not, here’s a quick overview. First, the BPCI initiative is a voluntary pilot program that is testing an alternative to the traditional fee-for-service reimbursement model that pays a hospital or clinic whenever it provides treatment—regardless of outcome. Bundled payments, on the other hand, link all healthcare providers for an episode—such as hip or knee replacement surgeries that involve various treatments—and then evaluates outcomes of cost and performance. CJR was introduced earlier this year to test a new reimbursement model for Medicare hip and knee replacement surgeries. Also known as lower extremity joint replacements (LEJRs), it is one of Medicare’s most common inpatient surgeries. Both BPCI and CJR are designed to reward hospitals (or participant physician groups, in the case of BPCI) for improving care coordination and achieving cost savings aligned with a target price determined by CMS based on the participant’s historical performance. When the hospital reduces episode costs below the target price, they receive a share of the savings. If payments remain above the target price, the hospital may owe a reconciliation payment to CMS. Since the CJR program and the BPCI initiative are similar in structure and design (with 83 percent of BPCI episodes included in the CMS report identified as orthopedic episodes) there are lessons to be learned in the report and applied to organizations affected by CJR and other burgeoning bundled payment initiatives. Some top takeaways:

Post-Acute Care Management is Key to BPCI Episode Spending

BPCI initiative participants that saw the most reduction in episode spending were those that achieved a marked decrease in SNF (skilled nursing facility) utilization, some up to almost five percent reduction compared to baseline.

BPCI Care Quality is Not Suffering

The BPCI initiative has its share of critics that are justifiably concerned about its potentially negative impacts on quality. However, the orthopedic BPCI data is thus far indicating that quality outcomes have remained high for participants, with no significant changes from baseline.

BPCI is Resulting in Episode Payment Savings

This early data shows that almost 90 percent of BPCI participants achieved a decline in episode payments. There has been an estimated $2000 per-episode average decline in payments correlated with appropriate utilization of post-acute care facilities and decrease in length of stay, among other factors.

Patient Management Proving to be Crucial BPCI Success Factor

Those that are targeting patient management resources are seeing the successes outlined above. This includes: • Workflow redesign • Care coordination • Case management • Patient navigation Although there is still not a universally agreed upon set of best practices for patient management and BPCI success, the data is indicating that a combination of activities are pulling healthcare providers in the right direction, such as: • Leadership buy-in • Resource allocation • Patient-centered care teams With these lessons learned from the BPCI Year 2 Evaluation, do you have the tools you need to be successful in CJR? Contact Guideway Care to learn how you can optimize the patient care coordination process using the Sequence platform.

How are MACRA and CJR Connected?

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Most people involved in healthcare—especially as it relates to Medicare reimbursements—are generally familiar with with MACRA (the Medicare Access and CHIP Reauthorization Act of 2015) and CJR (Comprehensive Care for Joint Replacement). However, what might they might not fully understand is how MACRA and CJR are connected. The simplest answer is that MACRA and CJR are connected by the Centers for Medicare & Medicaid’s goals for improving outcomes and reducing costs through value-based reimbursement and bundled payment models rather than the traditional fee-for-service model. A critical path for achieving this is to ensure that your hospital or clinic is prepared for better patient communication and management. However, to more fully understand the connections between MACRA and CJR—and how patient management technology fits in—it’s best to first briefly examine these concepts and what they strive to change or improve.

Fee-for-Service vs. Value-Based Reimbursement Care Models

More thorough examinations of fee-for-service vs. value-based reimbursement care models can be found on this blog and throughout the Internet. But most simply, the key differentiator between fee-for-service and value-based care is the difference between “quantity vs. quality,” respectively. The fee-for-service model rewards healthcare providers based how many patients and treatments a healthcare provider sees and provides (read: quantity), as where the value-based model rewards providers based on how well it treats them (read: quality)—as determined by CMS standards that include outcomes and satisfaction.

What is MACRA?

Enacted by the U.S. Congress in 2015, MACRA is a value-based payment system (also known as a “quality payment program”) to be associated with Medicare services. More can be learned about MACRA’s quality payment program rollout for January 2017, but one of its primary features is the introduction of two payment tracks:

• Merit-Based Incentive Payment System (MIPS)

• Alternative Payment Models (APMs)

Another primary MACRA feature will be the replacement of three existing quality reporting systems with a streamlined, more effective alternative.

What is CJR?

CJR was introduced earlier this year to test a new reimbursement model that encourages and rewards efficiency and satisfaction for Medicare hip and knee replacement surgeries. Also known as as LEJR (short for “lower extremity joint replacements”), it is one of Medicare’s most common inpatient surgeries.

Putting It All Together: Linking MACRA, CJR and Value-Based Care

LEJR treatment and recovery requires care from a spectrum of caregivers, including hospitals and post-acute care. Rather than reimbursing each with the fee-for-service model, CJR utilizes a “bundled payment” model for each “episode”—which is designed to encourage all caregivers to work together towards the same goals for which MACRA is intended:

• To reduce visit frequency and in-patient procedures

• To increase satisfaction, rewards, and patient-reported outcomes

Those that are prepared for the MACRA/CJR transition will be better positioned to be rewarded economically; those that aren’t may be penalized. A crucial factor for being well positioned is to have technologies and systems that can streamline patient care coordination with workflow management. Are you prepared to deliver and document value-based care to ensure you maximize your earning potential under reimbursement models that feature bundled payments? If not, contact a Guideway Care representative to learn about our CJR bundled payment program solutions.

Fee for Service vs Value Based Care in Healthcare Payment Reform

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Payments in the medical world have long been a point of debate, especially as the cost of health care continues to rise. Fee-for-service payment structures have historically been the norm, allowing physicians and medical centers to bill for each appointment, test, and procedure performed. However, as quality of service evolves and demands for standards of care increase, so do the possibilities for payment. Lead by CMS, or Centers for Medicare and Medicaid Services, the medical culture in the United States is moving away from its roots and into a new era of value-based pricing. Deviating from traditional norms is generally a challenge, especially for hospitals whose staff and technology support fee-for-service care. However, with support from the right software platform, it’s possible to bring any medical facility into the new horizon of patient-focused care.

Fee-for-Service

In the wide world of medical payments, fee-for-service has been the standard throughout much of the modern world of medicine. Under this systems, billing and payments are determined based on the procedures performed by a doctor as opposed to the outcome achieved through medical care. While initially a strong concept, the current climate has shifted. Increasingly, physicians are feeling pressure to perform ancillary testing and optional procedures for the purpose of billing insurance companies rather than generating results.

Value-Based

As the name implies, value-based care is assessed, and rewarded, based upon the value practices and procedures offer patients. Instead of taking a numbers-based look at the services performed, value-based healthcare delves deeper, providing payments based on successful outcomes and healthy patients rather than the number of procedures used to get there. With a marked emphasis on lower costs of care and reduced time spent in in-patient facilities, this approach attempts to qualify, not quantify, the medical climate in the United States. While value-based systems are still in their infancy, numerous medical bodies, including CMS, are pushing for complete industry reform.

Deciphering the Difference

In an ideal world, fee-for-service and value-based systems will not at odds with one another, but rather working in tandem to provide the best possible patient experience. For example, a standard annual physical cannot necessarily be evaluated in a value-based manner, requiring a fee-for-service approach. These changes are instead intended to provide a uniform standard of care in surgical and procedural cases, such as CMS’s proposed Comprehensive Care for Joint Replacement program and the passage of the Medicare Access and CHIP Reauthorization Act of 2015.

Making the Transition

With countless medical records platforms and billing systems built around a fee-for-service model, incorporating value-based payment bundles into a practice can be exceptionally daunting. Transitioning away from fee-for-service may be beneficial in the big picture, reducing patient stay durations, costs of care, and penalties from payers, but the implementation process can be both time consuming and costly. Rather than facing extra fees and billing complications, the right software support system can ease the burdens of applying a new approach to billing and payment collection.

View our archived webinar: How Sequence Can Help You Succeed in the Balance of Volume-based and Value-based Outcomes by Measuring these Four Pillars of Care

Guideway Care specializes in meeting and maintaining the needs of medical practices and hospitals of all shapes and sizes, ensuring a simple transition for your needs. By streamlining the changeover, reducing paperwork, and saving time, our proprietary system can assist you in taking your healthcare into the future. When you’re ready to adopt value-based payments as a part of your practice, Guideway Care can make the process as easy and possible. Contact us today to learn more about our unique approach to medical innovation.  Guideway Care Sequence of Activation Phone: 888.986.3638 Fax: 770.234.3815 Email: info@sequencehealth.com

Know Your Earning Potential with Bundled Payments and Value-based Care

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The increase in value-based care initiatives tied to bundled payments indicates big changes in the healthcare industry that affect the way patients receive care and providers measure success. As technology and medicine continue to advance, so does the way doctors engage patients to create meaningful relationships resulting in better patient outcomes. Traditionally in the United States, payment for healthcare treatment has been based on a fee-for-service model – the more patients receiving service, the more reimbursement for the provider, but that model is quickly changing. Hospitals, practices, and even clinicians are now paid according to value-based care reimbursement models. Quality and outcome standards are used to determine pay rates in response to a need for care that improves health rather than demands services. Organizations, and even individuals, are rewarded for meeting target costs and improving patient satisfaction and outcomes, while penalties are assessed for those unable to meet standards set by CMS. Guideway Care offers a suite of solutions allowing doctors and patients alike to benefit from new standards in efficient care delivery, effective patient experiences, and payment models that make sense under today’s value-based care programs.
What Is Value-Based Care? Historically, doctor’s services are charged on a per-procedure or appointment basis. As such, many doctors feel pressured to perform a long list of procedures and tests that may or may not be necessary. In time, this cycle leads to longer patient hospital stays, more patients at one time, and often unnecessary ancillary testing. Instead of putting pressure on healthcare providers to perform potentially-needless procedures, value-based care focuses on medical decisions with the patient’s health and best interests in mind. When properly incorporated, this approach to medical treatment can ultimately reduce visit frequency and in-patient procedures while increasing satisfaction, rewards, and patient-reported outcomes.
CMS Leads the Transition to Value-based Care For facilities that work with Medicare, complying with value-based mandates may or may not be required by CMS, or Centers for Medicare and Medicaid Services. CMS currently oversees a number of value-based bundled payment models, including CJR that affects orthopedic practices in 67 different regions across the country, and will be rolling out the new MACRA incentive-based payment system in 2017. Comprehensive Care for Joint Replacement (CJR) Commonly known as CJR, Comprehensive Care for Joint Replacement seeks to address one of the most common orthopedic inpatient procedures for Medicare patients: knee and hip replacements. Designed in an effort to standardize quality and cost of care, CJR replaces fees for related services with a bundled payment method, regulating the procedure, recovery duration, and more. Medicare Access and CHIP Reauthorization Act (MACRA) Passed in 2015, the Medicare Access and CHIP Reauthorization Act, or MACRA, is an incentive-based payment system to be associated with Medicare services. Utilizing two tracks for payment, Merit-based Incentive Payment System (MIPS), and Alternative Payment Models (APMs), MACRA is intended to replace three existing quality reporting systems with a streamlined, more effective alternative.
Leveraging the Sequence Platform By treating healthcare technology as a tool, not an industry, it’s possible to increase quality of care while reducing paperwork and honing the focus on paying for what works rather than what can increase billing. Guideway Care can streamline this transition, easing the workflow impact of physician teams and making workflow management, patient engagement, and care plan adherence painless. With our unique technology related to hospital and provider management, our suite of solutions alleviate your burden, increase efficiencies, and simplify your care team’s day-to-day routine. Are you prepared to deliver and document value-based care to ensure you maximize your earning potential under reimbursement models that feature bundled payments? Contact Guideway Care today to learn more!