The shift toward value-based care and changing payment models has been a hot topic this year, and the idea that fee-for-service (FFS) will be left in the dust seems to be a foregone conclusion. At the beginning of 2015, CMS set some lofty goals for switching to rewarding value: by 2018, it hopes to have 50 percent of all Medicare FFS paid through alternative payment models. It defines this as “category 3 and 4” of its payment toxonomy framework, which includes payments triggered by delivery of service with opportunities for shared savings and provider risk, as well as payment linked to long-term beneficiary care not directly triggered by volume of service delivery. CMS intends to have an extra 40 percent of FFS payments either in these categories or at least somewhat linked to quality and efficiency.
Are these goals realistic?
The Academy Huron Institute reviewed the evolving trends in population collaboration, noting that advancement of value-based payments require providers and health care organizations to take on additional risk. Health systems reported about an average of a quarter of their revenue being generated in an at-risk environment, but most expected this to grow significantly by 2020, with projections averaging around 50 percent. To ensure that these new payment models work, providers, insurers, and their employers must be willing to take on risk and participate. Those surveyed by the Institute felt that health systems are at the forefront of developing an infrastructure that works well with risk-based payments, and that employers and insurers were not yet at an advanced stage of preparedness for risk. Compensation models for physicians, however, still have a long way to go to be considered value-based.
Insurers
Insurers may be farther along than health systems think. Aetna reported that over a quarter of its reimbursements come through value-based contracts, and is preparing for that to become three-quarters of reimbursements by 2020. As far back as 2012, about 20 percent of Blue Cross and Blue Shield (BCBS) companies’ claims involved value-based care, amounting to over $65 billion. In 2012, BCBS reported that these contracts saved $500 million, as hospital care was reduced by fewer emergency visits and admissions and improved access to preventative care.
Better IT use is a must
One of the biggest barriers to population health seems to be information technology (IT). Earlier this year, the editor-in-chief of Healthcare IT News identified five obstacles to population health (for which he noted an exact definition has not been nailed down). These include lack of clinician compliance, insufficient care coordination, and information overload. Overall, these concerns seem to speak of a lack of unity: patients are not engaged, care overlaps and gaps remain, doctors want to continue doing things their own way, and there is too much information to analyze between claims data and electronic health records (EHR).
An underused resource
A HIMSS Analytics poll revealed that 67 percent of responding organizations were active in population health management, but only a quarter of them use vendor-provided technology for these efforts. About 11 percent have used a population health consultant to provide assistance in enhancing their programs. Another poll revealed that most primary care providers looking to replace their EHR systems want to have data analytics and population health management capabilities.
On the patient side, Kentucky is increasingly utilizing “population health coaches” in an effort to foster understanding and engagement. These coaches, often nurses, serve as a liaison between doctors and patients, providing additional information and instructions when patients are confused or concerned about their care. This resource is particularly valuable in environments with an absence of care coordination efforts for patients who see many different doctors. These coaches can review all of a patient’s medications and keep an eye out for interactions, or coordinate with various services like home health. One such coach points out that Medicare patients are often covered for this benefit, and insurance companies will even cover low-risk consumers to ensure that preventive care is pursued.