The transition from fee-for-service to value-based care is well under way. But while methodologies have evolved, the systems and processes that plans and providers rely on lag behind.
Fee-for-service accounting is based on individual charges for tests, treatments, and consultations. Providers determine the service needed to address the problem that the patient currently presents, and financial staff bill insurance companies accordingly. Documentation is similarly focused on establishing medical necessity for isolated episodes of care and reimbursement occurs regardless of patient outcomes.
Consequently, patient care in fee-for-service models is appointment-driven and narrowly focused on addressing the problem at hand. Providers evaluate and treat patients when illness occurs but aren’t required or incentivized to consider overall wellness and care beyond their own facilities.
Value-based care shifts the focus from reactive sick care to proactive management of overall health. Providers are reimbursed for the quality of care rather than the quantity of services provided. Determining reimbursement based on projected risk and outcomes is a much more complex calculation than issuing payment for units of service according to contract terms. There is an increased documentation and reporting burden both in terms of precision and scope. Providers must capture important elements about each potential diagnosis based on specific criteria, and provide additional documentation to reflect outcomes and results once treatment has begun.
Likewise, value-based patient care requires a more complicated set of responsibilities. The goal is to keep patients healthy through preventative measures and early detection of risk factors. Treatment plans are developed based on a wide range of data including records from everywhere patients received care and social determinants of health.
Value-based care providers are not only responsible for incorporating a wider range of factors into clinical decision making, but also for monitoring patient activity across settings. Primary, specialty, and acute care providers work together towards the common goal of achieving the best possible outcomes for their patients. Team members can work within the same facility, but more often than not are spread across different locations along the continuum of care, including the patient’s home. In contrast to fee-for-service models where providers operate in silos, communication is key to care coordination in value-based care models.
The benefits of value-based care are generally agreed upon throughout the healthcare industry. But the systems and processes healthcare professionals have relied on for decades were built for a fee-for-service world of volume over value. EHR's for example, are still, and will continue to be for the foreseeable future, the primary tool used for documentation and data management. EHR systems have many strengths, but core issues are exacerbated in value-based care models that rely on comprehensive patient portraits. Unintuitive workflows make it difficult for providers to document with the precision required for risk-adjustment. Extracting EHR data for use with analysis tools is also a cumbersome process as an estimated 80% of EHR data is unstructured, with multiple free-form fields and external data stored as static PDF files. Lack of interoperability is also an ongoing issue. Most EHR's only offer integration with other users of their system or for their own proprietary applications, so sharing information among care team members, let alone with other providers and payers, is still a burdensome process.
Despite these challenges, organizations can make strides towards value-based success right away by incorporating proactive processes into current systems. Supporting providers ability to document correctly and completely within EHR workflows is a particularly effective way to start. Payers and clinical support staff can determine all relevant conditions and related factors that may require evaluation ahead of encounters. To avoid shifting further administrative burden onto providers, the data should be easily digestible and presented within current HER workflows. Providers can then focus on addressing all relevant conditions without logging into various interfaces and hunting through documentation.