The shift from a volume to a value-based care model has completely transformed the healthcare industry. Value-based care reimbursement is based on quality and clinical outcomes, as opposed to the number of services provided.
Rather than following the traditional fee-for-service payment model, health plans utilizing value-based programs encourage healthcare practices to focus on overall quality of care to improve patient outcomes and consequently raise revenue. These “fee-for-performance” payment models require reimagined care delivery across the board-- from primary care physicians to hospitals and accountable care organizations -- and for providers, adapting the way they serve patients to achieve desired health goals is easier said than done.
Here are seven of the most common barriers to value-based care and how healthcare practices can overcome them.
1. Siloed patient information
Interoperability issues have been a pain point within the healthcare industry for some time and is one of the most significant challenges of value-based payment models.
When patient data is inaccessible to healthcare providers, measuring performance is virtually impossible. Today, many aspects of healthcare are driven by data, from treatment decisions to purchasing and beyond. However, multiple healthcare organizations have trouble collecting and reporting patient information, which makes effective care coordination and preventative medicine incredibly challenging.
Siloed patient information poses a significant barrier to healthcare organizations striving to achieve value-based care goals and deliver high-quality care. When patient data is compartmentalized or isolated within disparate systems, it creates inefficiencies and inconsistencies that can compromise patient care, hinder coordination among providers, and drive-up costs.
Providers that do not have a holistic view of a patient's health history have a limited ability to make informed, effective decisions. It can also disrupt efforts to track and improve health outcomes on a large scale.
Healthcare organizations need modern, integrated solutions that work together seamlessly to gather patient data into one source that allows healthcare organizations to track patient outcomes and inform medical decision-making across the enterprise.
2. Inefficient practice workflows
Outdated workflows can hinder progress when it comes to achieving value-based care measures by creating delays, fostering inaccuracies, and inhibiting the overall quality of patient care.
Manual processes, a hallmark of outdated workflows, often necessitate slow, labor-intensive tasks such as physical document retrieval, manual data entry, and hand-off communications. This often leads to significant delays in accessing critical patient information, disrupting timely decision-making, and impacting the ability to provide prompt, effective care to patients.
Moreover, manual workflows are prone to human error, introducing potential inaccuracies into patient records and diagnosis processes. Mistakes such as misrecorded patient information, overlooked data, or miscommunication can directly impact patient outcomes, leading to complications or inadequate treatment plans that could compromise the quality and safety of patient care.
Ninety percent of providers offer some form of a patient portal, and patient portals can play an instrumental role in helping healthcare organizations achieve value-based care goals by streamlining practice workflows. When used to their fullest capability, these digital platforms provide a unified, easily accessible space for patient data, significantly reducing the need for manual record retrieval and data entry, and thus minimizing the risk of human error.
In addition, patient portals also facilitate efficient communication between patients and providers, encouraging proactive health management and enhancing patient engagement—two key tenets of value-based care. For many healthcare practices, making full use of their patient portal is the first step to value-based care success.
3. Provider resistance to value-based care programs
Encouraging clinical staff to buy into workflow changes aimed at achieving value-based care goals involves a combination of clear communication, inclusive decision-making, and comprehensive training.
First, it's crucial to communicate the rationale behind the changes, highlighting how they will enhance patient care, improve job satisfaction, potentially simplify tasks, and raise reimbursement. Providing tangible examples and data demonstrating the positive impact of such changes on other organizations can also help build a persuasive case.
Second, involving staff in the decision-making process and giving them a voice in shaping these changes can boost ownership and acceptance. This can be achieved through regular meetings, focus groups, or suggestion boxes.
Finally, offering comprehensive training ensures staff are equipped with the necessary skills to adapt to new workflows. This should include practical demonstrations, hands-on practice sessions, and ample opportunities for questions. In addition, addressing concerns promptly, offering ongoing support, and acknowledging staff efforts in embracing these changes can further drive buy-in and commitment to achieving value-based care goals.
4. Fragmented patient care
Fragmentation of care delivery is a common barrier to providing high-quality, affordable healthcare. Fragmentation occurs when health care organizations and providers fail to collaborate and coordinate their efforts to provide seamless, holistic care for each patient. This lack of cohesion can cause gaps in healthcare services, resulting in sub-par outcomes and inflated costs from unnecessary services. Creating multidisciplinary care teams that coordinate and communicate effectively can reduce the overall cost of care and improve both patient satisfaction and outcomes.
For example, if a patient is transitioning from the hospital to a rehabilitation facility or home care, the physicians, specialists, and nurses at said health system should coordinate with the patient's primary care provider (PCP), physical therapists, and other associated clinicians. This ensures everyone on the integrated care team is up-to-date and aware of the patient's health history, medical issue, functional status, failed treatments, and more.
Patients that are managed across the care continuum have a greater likelihood of avoiding the poor outcomes that penalize providers in value-based payment programs.
5. Managing health outside of the patient visit
The majority of patient care transpires outside the confines of the doctor's office, during the individual's day-to-day life, when habits, behaviors, and personal health management practices play a significant role. For providers to excel in value-based healthcare, it's crucial to extend their visibility into this realm of patient health. This is where technology tools, particularly those designed to capture patient health data between visits, become invaluable.
Organizations need to use technology that collects patient-reported outcomes (PROs), analyzes patient data points, and triggers appropriate next-steps according to patient responses to improve outcomes for patients.
Many patients, especially patients with chronic disease, use devices and apps to track health data including blood pressure, blood sugar levels, physical activity, medication adherence, and more. The challenge for providers is capturing and recording these real-time insights into meaningful information to inform care. One solution is to use digitized patient surveys that collect, analyze, and respond to PROs that helps providers make informed decisions about care adjustments, prevent potential health crises, and ensure adherence to treatment plans.
6. Elevated financial risk
In a recent survey, one in five respondents cited the threat of financial loss as their primary barrier to value-based care. This is understandable. One of the primary barriers in moving towards a value-based model is the unpredictable revenue streams and financial risk that it entails.
Healthcare organizations can face substantial financial penalties if they fail to meet the objectives of value-based care programs. These models, implemented by regulatory bodies like the Centers for Medicare & Medicaid Services (CMS), typically operate on a system of rewards and penalties based on the quality of care provided. Failure to achieve specified benchmarks or demonstrate continuous improvement in areas such as patient outcomes, readmission rates, patient satisfaction, and preventative care can result in significant reimbursement reductions.
For example, under CMS's Hospital Readmissions Reduction Program (HRRP), hospitals with higher than expected readmission rates for specific conditions can face reductions in their Medicare payments. Similarly, under the Merit-Based Incentive Payment System (MIPS), eligible clinicians can receive payment adjustments based on performance in quality, promoting interoperability, improvement activities, and cost. These penalties can impact an organization's bottom line, emphasizing the necessity of meeting value-based care goals to ensure financial sustainability.
At first glance, it seems like an unrealistic proposition for healthcare professionals to be expected to control patient health outcomes -- especially for those with chronic conditions that are the focus of value-based quality metrics.
However, creating new clinical workflows can allow many organizations to reduce healthcare costs while increasing patient interactions that will lead to better health outcomes. Introducing new types of clinicians such as nurse practitioners, pharmacists, physician assistants, registered nurses, medical assistants, and community health workers can be an effective way of improving patient access to care and enhancing outcomes.
7. Focus on cost rather than care
The increasing focus on reducing healthcare spending has led to a greater reliance on “shared savings” payment models. This approach ties payment to a provider’s ability to keep total spending on their patients at or below an established level. Those who meet this threshold are eligible for incentive bonuses, though many of these programs have recently begun to include incentives that require downside risk, meaning providers must pay out penalties if the payer’s amount spent exceeds expectations.
The most well-known programs implementing this approach include the Medicare Shared Savings Program, BPCI (Bundled Payments for Care Improvement), and CJR (Comprehensive Care for Joint Replacement) from the Centers for Medicare and Medicaid Services (CMS). Although these programs add an element of performance-based rewards, they are primarily based on using standard fees for individual services, meaning that any positive incentive is derived by simply avoiding financial losses.
Labor represents one of the most significant expenditures in the healthcare sector, with administrative costs often consuming a substantial portion of staff time. Streamlining these processes, particularly those related to patient intake, can yield considerable labor savings. Tools such as digital forms and automated patient intake systems eliminate the need for manual data entry, reduce paperwork, and free up staff to focus on more critical tasks. Studies have shown that the adoption of such systems can reduce administrative labor costs $25 billion dollars a year, highlighting their cost-saving potential.
Furthermore, these systems can lead to increases in patient satisfaction. Patients appreciate the convenience of completing forms at their leisure, reducing waiting times, and facilitating a smoother, faster check-in process. The enhanced patient experience, coupled with the tangible financial savings, underscores the value of incorporating digital solutions into healthcare workflows.
Overcoming challenges of value-based care with technology
Many of the recommendations outlined above have one common denominator: technology.
With the right technology, healthcare practices and providers can face the biggest challenges in value-based care head on and provide top-quality patient care in the process.
The top 5 ways technology can enhance value-based care initiatives:
1. Enhanced data integration and interoperability: Technology allows different healthcare information systems to communicate, share, and use data more effectively. With robust Electronic Health Records (EHRs) and Health Information Exchange (HIE) platforms, healthcare providers can access and share critical patient information efficiently and securely, enhancing coordinated care, improving patient outcomes, and reducing costs.
2. Advanced filters: Technology that can find patients according to diagnosis, procedure, or health metrics such as BMI can help providers create and execute campaigns aimed at early interventions, personalized treatment plans, and better awareness of social determinants of health factors, all key to achieving value-based care goals.
3. Telemedicine and remote patient monitoring: Technology allows for continuous monitoring of patients outside traditional healthcare settings, particularly beneficial for chronic disease management. It also facilitates telehealth visits, ensuring timely care delivery without geographical constraints. This results in reduced hospital readmissions, improved patient compliance, and increased patient satisfaction.
4. Streamlined administrative workflows: Automating administrative tasks such as patient scheduling, billing, coding, and patient intake can save significant time and reduce human errors. Digital solutions can enhance the efficiency of these processes, improving staff productivity and patient experiences, and allowing more resources to be focused on direct patient care.
5. Patient engagement tools: Patient portals, digitized patient intake, automated surveys that capture, analyze, and act upon PROs, and secure messaging help patients engage in their care. These tools provide access to health records, appointment scheduling, prescription refills, and educational resources, promoting patient self-management, which is critical for successful value-based care.
In conclusion, the transition from volume-based to value-based care is a complex journey, fraught with multiple challenges. However, with strategic planning, collaboration, technological investment, and a patient-centric mindset, these obstacles in the value-based care landscape can be overcome and produce improved outcomes for patients.
Ensuring interoperability, streamlining practice workflows, securing staff buy-in, providing holistic care, harnessing technology for remote monitoring, managing financial risks, and focusing on care rather than costs are vital elements to be considered.
Amid the challenges, the ultimate goal remains - delivering high-quality, coordinated, and cost-effective care to improve patient outcomes. By leveraging data, embracing innovation, reducing administrative burdens, and cultivating a culture of continuous learning and adaptation, healthcare organizations can thrive within value-based care models and elevate the standard of healthcare delivery. It's a transformative journey that holds the promise of a more sustainable, efficient, and patient-centered healthcare system, a shift that ultimately benefits both the providers and the patients they serve.
This article was originally published in October 2020 and was updated in June 2023.