Despite the U.S. government pouring trillions of dollars into healthcare, the system remains plagued by inequities and unmet demands! Do you know why? Researchers have found that the real problem lay in the old fee-for-service healthcare billing model. According to this model, providers were used to getting paid only for the services they provided, no matter the results they generated. Thus, U.S. healthcare heads have taken a step towards a result-driven healthcare program called value-based care.

Value based care model introduces equity by providing reimbursements to providers for the quality of healthcare they provide. Now, the patient experience will determine the quality of care a provider has delivered, not the volume of services he has provided.

What Is Value Based Care Model & Its Components?

The revolutionary value based care program is a healthcare delivery program by CMS that focuses on the quality of care provided, patient experience, and the cost-effectiveness of the treatment. Here is how this program works:

1. Focus on Outcomes

Value-based care focuses on paying healthcare providers depending on how much improvement a patient gets out of a provider’s effort as compared to the amount of treatment they get from that healthcare provider. This incentivizes the providers to provide and maintain preventive care, keep chronic illnesses in check, and maintain the overall health of the patient for a longer duration. The VBC program emphasizes the need to manage health conditions and to provide additional bonuses on the basis of improved treatment outcomes to ensure long-term patient recovery and thus the effectiveness and efficiency of the health services being provided.

2. Patient Engagement

Another difference between fee-for-service and value based care models is that in the former models, the patients passively received the services, but the latter seeks to engage the patient in the decisions regarding their care. The model here is such that the doctors work in partnership with the patients in order to determine the key aspects regarding the patient’s concerns, values, preferences, and health goals to provide interventions that are personalized to the patient. This approach enables the patients to be deliberate in their choices for treatment that would suit their general welfare as human beings.

When patients are engaged in their own care and understand why their physician made these decisions, they are more likely to follow the course of the care plan, which includes taking medications, showing up for follow-up appointments, and even making a lifestyle change. This will subsequently result in improved health outcomes and, as such, enhanced payments for the providers.

3. Integrated Care

The most important advantage of value based program is integrated care, where all your doctors collaborate with each other for the betterment of your health. Patient-Centered Medical Homes (PCMHs) are the most important pillar of the VBC model, where your primary care physician, cardiologist, physical therapist, and all other providers work together, share your medical history, and collaborate on a unified treatment plan. This collaboration through EHRs eliminates fragmented healthcare and helps providers develop comprehensive and coordinated treatment plans that address all aspects of a patient’s health condition.

Communication and collaboration also prevent unnecessary duplication of tests, procedures, or appointments and reduce the overall healthcare cost. So, as a provider, the more you assist in reducing patient costs, the greater the benefits you can attain through the value-based care model.

4. Performance Measurement – VBC’s Compass for Improvement

The traditional fee-for-service model is used to measure providers by the volume of services they deliver, but value based care has flipped this concept and focuses on quality, outcomes, and efficiency. Doctors and healthcare providers are now evaluated on the basis of a defined set of metrics that encompasses various aspects of care delivery. These metrics can be broadly categorized into three areas, which are as follows:

i. Clinical Quality: Measures like patient health outcomes, which may include blood pressure control rates for diabetics, hospital readmission rates after surgery, and more, can be used to assess the effectiveness of treatment provided. These measures demonstrate the quality of clinical care provided to patients by healthcare providers.

ii. Patient Experience: PROMS (patient-reported outcome measures) and satisfaction surveys gauge the patient’s experience, which is considered the most important aspect of value based care program. The patient experience here includes wait times, communication with providers, and the overall satisfaction of the patient in the whole healthcare journey.

iii. Cost Efficiency: The value based care model effectively measures the cost of care used per patient to evaluate how efficiently healthcare resources are being used in the process. It involves the utilization of all resources required to provide the whole treatment and emphasizes avoiding unnecessary tests or procedures. This action makes this program actually a value-providing program that values the money of patients and rewards the providers who cut the cost for patients and make cost-effective care reachable.

Many organizations have developed standardized frameworks for measuring performance in a value-based care model. A prominent example is the National Quality Forum, which publishes a set of evidence-based performance measures that can be used to assess various aspects of care quality. The data collected from performance measurement can also serve providers as a tool for identifying areas for improvement and benchmarking themselves against others.

5. Focus on the Whole Person – A Holistic Approach to Health

Where traditional healthcare focuses on treating the physical symptoms of a disease, value based care takes a more comprehensive approach. It focuses on the fact that a person’s well-being is influenced by a complex interplay of physical, mental, and social factors. Value based care considers the whole person and aims to address the underlying issues that might be contributing to a patient’s health problems. This is a holistic line of action that considers mental and social factors that can lead to more sustainable and positive health outcomes in the long run.

By focusing on the person’s mental and social factors, value based care programs also address social determinants of health (SODH). This SODH includes access to healthy food, safe housing, and the economic stability of a patient. VBC prioritizes providing resources for healthy eating habits and stress-free living that will ultimately help prevent health problems before they arise.

6. Health Equity

Historically, value based healthcare access has been unevenly distributed across different populations in the USA, but current value based care programs promote health equity. Disparities in healthcare outcomes based on race, ethnicity, socioeconomic status, and other factors used to exist in the past. Value based care bridges this gap by ensuring everyone has access to high-quality care, regardless of their background.

How Does VBC Healthcare Affect Your Reimbursements?

Value based care program motivate providers to deliver better quality care with financial incentives. These incentives come in various forms, with some rewarding performance on patient cost-cutting, quality, and equity metrics mentioned above. There is an “upside-downside risk” where providers can gain or lose revenue based on meeting these metrics.

Another important aspect of value based care that affects reimbursements is “prospective payment,” which gives providers money upfront to manage care for a defined group of patients. This approach encourages more efficient care, as the more a provider’s income relies on value-based metrics, the more motivated they will feel to perform. These incentives ultimately aim to steer providers away from the fee-for-service model and towards delivering better healthcare at a sustainable cost.

What Is the Future of Value Based Care?

The future of value based care holds a huge value-added plan for U.S. citizens and providers, as CMS is aiming to enroll most beneficiaries in the VBC program by 2030. This approach encourages providers to deliver high-quality care and promote health equity for underserved communities through programs like ACO REACH. As participation is increasing, future models are supposed to be more financially rewarding and accessible, especially for providers serving disadvantaged or rural areas.

Furthermore, the integration of AI, big data analytics, and telehealth will improve care coordination, personalize treatment plans, and simplify administrative tasks.

How Medical Billing and RCM Services by Professionals Help You Follow the VBC Model Efficiently? 

Medical billing services and revenue cycle management assistance by professionals like those at Transcure help providers achieve their deserved reimbursements while following VBC. They can help you get the full benefits of value based program, and here is how they do it:

· Accurate Coding and Claim Submission: As you know, value based-care highly relies on accurate coding to capture the quality and complexity of care delivered. Expert medical coders ensure proper and accurate codes to reflect the services provided by the providers, which helps you maximize your reimbursements under value based models.

· Data Analytics and Performance Tracking: Performance tracking is very important if you want to achieve success in a VBC model. Here, RCM services can provide valuable data analytics on your key performance metrics used in value based care programs. This data can help providers track their performance on quality measures, cost-effectiveness, and health equity metrics. This kind of tracking will allow them to identify areas for improvement and optimize their care delivery.

· Assistance in Identifying Revenue Opportunities: Our RCM services can also help you identify new revenue opportunities under value-based payment models, such as bonuses or capitated payments for managing a defined patient population.

· Efficient Revenue Cycle Management: As value based care requires providers’ full time and attention, managing the revenue cycle and submitting claims on time can become a burden. However, efficient RCM processes by professionals ensure timely claim submissions and reduce administrative burdens for providers while they focus on patient care. 

Medical billing and RCM services act as a vital bridge between value based care programs and the financial stability of providers. You can rely on expert medical billers and RCM professionals at Transcure to ensure accurate reimbursements while following a value-based healthcare program. With our expertise, you will not only get your deserved reimbursements but also get valuable insights into your performance and eliminate administrative hassles.  

Conclusion

In the end, value based care is revolutionizing healthcare by shifting the focus from quantity to quality. This patient-centered approach rewards providers for delivering effective and efficient care that prioritizes positive health outcomes. To reach this extent of care, providers must not feel burdened and must seek professional assistance to manage their revenue cycle. In this way, they can easily give their 100% to providing quality care and get reimbursed more than others. 

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