The advent of value-based care models (VBCMs) reflect the Centers for Medicare & Medicaid Services’ (CMS) “larger quality strategy to reform how health care is delivered and paid for.” The principle of value-based programs relates to moving healthcare providers towards an outcomes-based approach, emphasizing quality over quantity of care.
CMS has introduced various VBCMs to reimburse providers for high-quality care. These models tie payments to the quality and effectiveness of services provided, incentivizing providers to deliver quality care. There are several models, each with its own set of goals and requirements.
Why Are CMS Value-Based Models Important?
Here are a few reasons why Medicare value-based care models play an important role in the future of healthcare:
- Improved patient outcomes: The goal is to impact better health outcomes by preventing hospital readmissions and complications, improving patient satisfaction, and enhancing quality of care.
- Improved patient experience: More personalized care means better communication between physicians and patients and a more individualized treatment plan that fits each patient’s needs better.
- Improved healthcare provider experience: Under this model, providers receive financial incentives based on their performance rather than being penalized for bad outcomes or poor customer service experiences.
- Better cost management: CMS value-based care models give health systems flexibility in how they choose their payment model. Using blended payments can help them earn additional revenue by providing high-quality care that improves patient outcomes.
Types of CMS Value-Based Care Models
Here’s a quick guide to some of the most important Medicare value-based care models:
End-Stage Renal Disease Quality Incentive Program (ESRD QIP)
End-Stage Renal Disease Quality Incentive Program (ESRD QIP) is a federal-run program that promotes quality improvement in dialysis care. The program sets standards for care and provides financial incentives to facilities that meet or exceed these standards. The goal of the ESRD QIP is to improve patient outcomes and reduce the costs of care.
According to CMS, the ESRD QIP scores facilities on their performance by achievement (comparing facility performance to a set of values derived from all facilities nationally) and improvement (comparing facility performance to the facility's individual performance during the prior year).
Hospital Value-Based Purchasing (VBP) Program
The Hospital Value-Based Purchasing (VBP) Program links reimbursement to the quality of care that hospitals provide to Medicare beneficiaries. The program rewards acute care hospitals’ performance compared to their peers and adjusts the reimbursement accordingly.
The measures that hospitals are graded on are:
- Mortality and complications
- Healthcare-associated infections
- Patient safety
- Patient experience
- Efficiency and cost reduction
Hospital Readmission Reduction Program (HRRP)
The Hospital Readmission Reduction Program (HRRP) “encourages hospitals to improve communication and care coordination to better engage patients and caregivers in discharge plans and, in turn, reduce avoidable readmissions.”
The excess readmission ratio (ERR) serves as the benchmark to assess healthcare provider performance. It’s calculated as a ratio of the predicted-to-expected readmission rates for the following conditions:
- Acute Myocardial Infarction (AMI)
- Chronic Obstructive Pulmonary Disease (COPD)
- Heart Failure (HF)
- Coronary Artery Bypass Graft (CABG) Surgery
- Elective Primary Total Hip Arthroplasty and/or Total Knee Arthroplasty (THA/TKA)
Value Modifier (VM) Program
The Value Modifier (VM) Program is an initiative that ties a portion of Medicare payment to the quality and cost-efficiency of care delivered to beneficiaries. The VM Program was created by the Patient Protection and Affordable Care Act (ACA) and was first implemented in 2014.
After each performance period, CMS calculates quality and cost-efficiency scores for each physician or group practice that saw Medicare patients during that period. These scores are then used to adjust Medicare payments for the following year.
Hospital-Acquired Condition (HAC) Reduction Program
Hospital-acquired conditions (HACs) are a significant problem in the healthcare industry. They could result in more extended hospital stays and higher costs.
The HAC Reduction Program is a nationwide initiative to reduce the number of HACs in hospitals. Specifically, it “encourages hospitals to improve patients’ safety and implement best practices to reduce their rates of infections associated with health care.”
The program applies to all subsections within acute care hospitals, with some exceptions such as:
- Critical access hospitals
- Children’s hospitals
- Psychiatric hospitals and units
- And more
An Example of VBC in Action
Value-based care not only improves outcomes, but engages care teams in creating a holistic care journey for patients as well.
Take James, for example. He is a 47-year-old with chronic kidney disease (CKD) living in in Houston, Texas. James is supported by a team within the Aetna Memorial Hermann Accountable Care Network. He visited the hospital with shortness of breath and swelling in both legs, indications that the symptoms of his disease were not controlled.
Patients like James may spend only a few hours each year in their doctors’ care but many more hours in self-care. Open communication and sharing of information among care teams, carriers and patients enhances trust and engagement and empowers patients to take better care of themselves between visits, critical elements for the success of prevention strategies and care management programs.
Evidence shows that care teams involved in value-based care are more likely to:
- Recognize that engaging patients in conversations about treatment plans and medications will help them achieve their desired outcomes
- Be aligned with patients’ motivations for their health goals
- Coordinate with community resources like nutritionists, social workers, in-home liaisons and mental health counselors to help patients meet their goals
How Telehealth & RPM Can Help Support VBCMs
Telehealth and RPM is a great way to support VBCMs and help organizations achieve their value-based care goals. Telehealth can help with care coordination and delivery, patient engagement, chronic condition management, and more.
Telehealth can also be used for care coordination by offering patients access to their health records through the platform, which works on tablets and mobile devices. This allows them to view their medical history, upcoming appointments, medication dosages, and prescriptions.
Patients who have questions about their treatment plan can communicate with their provider directly via virtual visits, which helps streamline interactions between the patient and provider while keeping costs down by saving on travel expenses.
How HRS' Solutions Help
HRS’ solutions enable you to monitor your patients post-discharge with its advanced biometric monitoring paired with a telehealth platform designed to improve patient engagement with condition-specific education, symptom surveys, medication reminders, teach-back quizzes, and more.