Deloitte Insights conducted a study among healthcare leaders to identify their top risk management concerns, and to measure industry preparedness for those risks. This study found that transitioning to value-based care is one of the top 3 risk priorities of health leaders today. The other 2 were consumer engagement and cybersecurity.

Top Risks For Healthcare Leaders

  • Consumer engagement (58%)
  • Transition to value-based care (55%)
  • Cybersecurity (55%)
  • Technology/digital transformation (53%)

Risk Preparedness For Value-Based Care

Despite being a top risk priority, 58% of healthcare leaders also say they are either only moderately or not prepared to handle the transition to value-based care. Most healthcare leaders have invested in or identified staff to address their top risks (73%), but less have actually invested in supporting technology (63%) or trained staff (58%).

As practices prepare for the shift to value-based care, they will need to implement a strategy of people, processes, and technology that work together seamlessly to make the transition without losing revenue. Practice leaders who have identified staff members to focus on the transition to value-based care are off to a good start, but they will need to invest in the right technology, and they will also need to train staff on correct processes.

Why Value-Based Care?

Value-based care is an alternative to the traditional fee-for-service reimbursement models. Rather than getting paid based on how many patients you treat or how many services you provide, you are reimbursed based on the outcomes and quality of the care you provide. Not all payers have transitioned into value-based reimbursement models; however, practices should prepare, as this is the direction that the healthcare industry is ultimately heading.

Types of Value-Based Reimbursement Models

There are several different value-based care models that healthcare providers can implement in their practice.

1. Pay-for-Performance Model

In Pay-for-Performance Models, providers are still reimbursed on a Fee-for-Service basis. However, they are also rewarded or penalized based on meeting quality thresholds.

2. Bundled Payment Model

In bundled payment models, providers receive reimbursement on the basis of an episode of care. Episodes of care includes all the services used to treat an illness or injury from the point of diagnosis all the way through recovery. This plan includes a fixed fee that covers the costs of physicians, drugs, devices, facilities, and any other resources expended for the episode of care. This type of reimbursement incentivizes providers to work together and to ensure there are no gaps in care as a patient moves through different settings and providers. Providers make more profit by keeping their spending below the average cost of an episode.

3. Accountable Care Organization Model

An Accountable Care Organization, or ACO, is a group of doctors, hospitals, and other care providers who come together to coordinate higher quality care at a lower cost. Providers are assigned a number of enrollees, and there is a benchmark spending target for that group. The actual spending is compared against the benchmark, and any savings are split between the providers.

4. Patient-Centered Medical Homes Model

This model focuses on coordinating patient care through a primary care physician. A centralized clinic is tasked with all aspects of care for each individual patient. The goal is to provide higher quality, personalized care, and to prevent hospital readmissions and emergency department visits. Providers in this model will usually negotiate higher Fee-for-Service rates, or monthly rates per member in addition to the traditional Fee-for-Service rates.

5. Capitation Model

In capitation models, providers are paid a fixed fee on a Per Member Per Month basis. The full risk is assigned to the provider. This is a population-based approach, and the goal is on prevention and wellness, as well as reduced costs when providing care. Providers who remain under the capitated rate makes money, and providers who spend over the capitated rate lose money.

Reduce Risk with Custom Rules

As we discussed previously, almost half of healthcare leaders have not invested in the technology needed to mitigate risks they are currently facing. When it comes to transitioning to value-based reimbursement, practices need to implement technology that will back up their processes. Custom rules will help catch coding changes you need to make to get paid in full. Learn more about how White Plume can help practices reduce medical coding risks.