Value-Based Healthcare and the Role of Nurse Practitioners

[offlabel]

Quote

 In the value-based approach, health outcomes are measured against the cost of delivering the outcomes.

What does "the cost of delivering the outcomes" mean? It would seem there would be a lot of emphasis on seeking out and 'caring' for the healthiest patients with the fewest co-morbidities and care for the most ill with multiple co-morbid patients would be de-incentivised. 

[Ruth Mielke, DNP, RN, CNM]

Value-based healthcare does benefit everyone. But, for it to be profitable, it all depends on how well the provider codes for the care they give. It's not just a matter of "If it wasn't charted it wasn't done." It's a matter of "if it wasn't coded for, then it wasn't done." 

[offlabel]

Ruth Mielke said:

Value-based healthcare does benefit everyone. But, for it to be profitable, it all depends on how well the provider codes for the care they give. It's not just a matter of "If it wasn't charted it wasn't done." It's a matter of "if it wasn't coded for, then it wasn't done." 

Like any other fee for service billing. You can bill for what you capture.  And it still sounds like healthy patients=profitable and sick patients, not so much. What am I missing here?

[Tegridy]

offlabel said:

What does "the cost of delivering the outcomes" mean? It would seem there would be a lot of emphasis on seeking out and 'caring' for the healthiest patients with the fewest co-morbidities and care for the most ill with multiple co-morbid patients would be de-incentivised. 

 

offlabel said:

Like any other fee for service billing. You can bill for what you capture.  And it still sounds like healthy patients=profitable and sick patients, not so much. What am I missing here?

The sick ones should have more HCC codes thus higher reimbursement

[Tegridy]

offlabel said:

What does "the cost of delivering the outcomes" mean? It would seem there would be a lot of emphasis on seeking out and 'caring' for the healthiest patients with the fewest co-morbidities and care for the most ill with multiple co-morbid patients would be de-incentivised. 

Also probably means not wasting money on tests that arent indicated

[Alice Blackmore, MSN, RN]

I have never heard of the concept of value-based healthcare before. Just to clarify -- would insurance companies pay more because the patient's chronic condition improved or they got better? I see the benefit for physician payment but am wondering about kick-back from insurance companies.

[NRSKarenRN, BSN, RN]

Value-based health care

Quote

The value-based health care movement is based on the work of Harvard University Professor Michael E. Porter. His landmark book, Redefining Health Care Creating Value-Based Competition on Results, was co-authored by Elizabeth O. Teisberg and published in 2006 following 10 years of research into why the health care industry did not conform to the principles of competition seen in all other sectors of the economy. They described how health care had fallen into a pattern of dysfunctional competition where providers were competing on the wrong things at the wrong level. The result was that the US health care system was spending more per citizen on health care than any other nation and getting worse health outcome in important areas like newborn mortality.

 

Quote

There are six major elements that are necessary in a truly value-based system

1. Organize Care Around Medical Conditions →  Care delivery is organized around patients' medical conditions or segments of the population.

2. Measure Outcomes & Cost for Every Patient → Outcomes and cost are measured for every patient.

3. Aligning Reimbursement with Value → Reimbursement models that reward both better outcomes and efficiency of care, such as bundled payments.

4. Systems Integration → Regional delivery of care organized around matching the correct provider, treatment, and setting.

5. Geography of Care → National centers of excellence providing care for exceedingly complex patients.

6. Information Technology → An information technology system designed to support the major elements of the agenda.

 

CMS' Value-Based Programs | CMS - Centers for Medicare & Medicaid Services

Value-based programs reward health care providers with incentive payments for the quality of care they give to people with Medicare. These programs are part of our larger quality strategy to reform how health care is delivered and paid for. Value-based programs also support our three-part aim:

• Better care for individuals
• Better health for populations
• Lower cost

What are CMS' original value-based programs?

There are 5 original value-based programs; their goal is to link provider performance of quality measures to provider payment:

1. End-Stage Renal Disease Quality Incentive Program (ESRD QIP)
2. Hospital Value-Based Purchasing (VBP) Program
3. Hospital Readmission Reduction Program (HRRP)
4. Value Modifier (VM) Program (also called the Physician Value-Based Modifier or PVBM)
5. Hospital Acquired Conditions (HAC) Reduction Program

Are there other value-based programs?

There are other value-based programs:

• Skilled Nursing Facility Value-Based Purchasing (SNFVBP)
• Home Health Value Based Purchasing (HHVBP)

 

OJIN 2019  Affordable Care: Harnessing the Power of Nurses

Quote

...The purpose of this article is to discuss the unique roles offering empowerment to nurses to drive and respond to financial concerns in healthcare through the lens of the three aims of the ACA: reducing cost, improving quality and increasing access. We discuss how nurses and the profession of nursing have harnessed the power of the discipline to make changes in these key areas, specifically the impact of nurses on national health cost reduction, value based healthcare reimbursement, and opportunities to impact healthcare quality. In addition, we consider the impact of nurses on healthcare quality and access to care, as well as continued opportunities for nurses to impact access and lead change....

...Patient Centered Medical Homes (PCMHs) focus on patients with chronic illnesses and accomplish cost savings through communication and coordination of care (Dunham-Taylor & Pincuk, 2015). PCMHs provide care across the continuum of health services and are rewarded for their number of patients (Burton, Berenson & Zuckerman, 2017). In this setting, a goal is to provide patient centered care that improves the capacity for self-management. This provides opportunity for clinical nurses and nurse practitioners to utilize transformational leadership skills to empower patients and the interdisciplinary team to create health management plans that are unique, quality driven, and patient focused....

...Nurses led the evolution of case management based on needs of populations they cared for in the hospital (NACNEP, 2010). Once organizers of interdisciplinary team rounds in hospital settings, nurses now find themselves in roles as APRNs directing patient navigation through health screenings, wellness checks, and preventive care. When nurses responded to health payment reform during the transition from cost based to DRG based reimbursement, they responded strategically through development of case management roles and processes to organize and lead interdisciplinary rounds; coordinate discharges via enhanced discharge planning activities; and offer leadership in utilization review. Nurses engaged physicians, pharmacists, and social work colleagues to identify post-acute care environments that offered lower cost discharge opportunities beyond high cost, short term, acute care hospitals when possible. When this was not feasible, providers considered venues that remained cost-based, such as long term acute care hospitals and sub-acute centers to care for chronically critically ill patients.....

Value-Based Care Elevates the Role of the Registered Nurse in Primary Care

Quote

...Additionally, the patient pathway from appointment preparation to next appointment rescheduling was streamlined to shorten wait time by starting intake procedures from the moment the patient enters the office. Further, the critical handoff between the physician and the nurse is expedited by the needs-based stratification of patients, each associated with evidenced-based care protocol.  This expands the role of nurse, allowing them to assume greater responsibility for patient care.    

The positive health outcomes are significant: improved diabetes management, increased breast and colon cancer screening, higher staff experience scores, and greater patient retention.

To be successful in such value-based initiatives, healthcare organizations must ensure nurses are working at the top of their license. Progressive providers have increased patient access by conducting new nurse-only patient visits during which registered nurses document patient histories, order lab and other diagnostic tests, and determine patient acuity.

By implementing newly defined standardized procedures, clinics are increasing the registered nurse's scope of clinical decision making including medication refills and anticoagulant and chronic care management. Nurses also are conducting physical examinations, providing triage, and subsequently presenting patient cases to practitioners—activities that significantly improve overall workflow and efficiency. Moreover, evidence shows nurse-led chronic, complex, and transitional care management results in decreased hospital days and emergency department (ED) admissions.

NP Journal:  Value-Based Healthcare

ANA: Reducing Barriers to NP Value-Based Care

National Nurse Practitioner Entrepreneur Network (NNPEN): NP Value In Value-Based Care

[JKL33]

NRSKarenRN said:

3. Aligning Reimbursement with Value → Reimbursement models that reward both better outcomes and efficiency of care, such as bundled payments.

The problematic (and straight up duplicitous) aspect of the whole thing summed up in a single sentence, right here ^

No one is getting "rewarded." The "reward" is simply getting paid for work already done, efforts already made and services already provided. Providers will generally get paid for the work they do with ideal patients: Those who have the means of accepting and adhering to recommendations and for whom the standard recommendations have a significant impact. In other words:  able to pay for the recommended treatment plan, physically, intellectually and emotionally able to adhere to and persist with recommended treatment plan, and have disease that is fairly straightforward and responds to the recommended treatment plan.

All those patients who struggle with any of the above? Their care either is NOT going to be "efficient" or will be less likely to have the "better outcomes" mentioned.

I would hardly say that "everyone" benefits from this model.

This is what is frustrating about healthcare, so much alternate reality, where people who want everything for nothing hear something and think it sounds good and run with it and half the people who should know better advocate it while everyone else cries bitter tears and gets completely fed up because it was a fantasy-level pie-in-the-sky initiative in the first place and is not possible.

 

[Joy Odafe, RN, APN]

offlabel said:

What does "the cost of delivering the outcomes" mean? It would seem there would be a lot of emphasis on seeking out and 'caring' for the healthiest patients with the fewest co-morbidities and care for the most ill with multiple co-morbid patients would be de-incentivised. 

Offlabel, thanks for your post. When we talk about the cost of delivering the OUTCOMES, we are simply looking at the cost it takes to deliver the quality of care provided versus payment based solely on the quantity of services regardless of the outcome. So, you can say the value-based model is outcome driven and not merely based on quantity of services provided.

In my experience value-based care has actually done the opposite. It incentivizes providers to be even more engaged with the most ill patients and those with multiple co-morbids.

The traditional fee-for-service model does encourage seeking out and caring for the healthiest since reimbursement is based on how many patients the provider sees regardless of the outcome.

[Joy Odafe, RN, APN]

Ruth Mielke said:

Value-based healthcare does benefit everyone. But, for it to be profitable, it all depends on how well the provider codes for the care they give. It's not just a matter of "If it wasn't charted it wasn't done." It's a matter of "if it wasn't coded for, then it wasn't done." 

Thanks for your comment, Ruth. Absolutely, coding is the name of the game. 

Tegridy said:

 

The sick ones should have more HCC codes thus higher reimbursement

True!

[Joy Odafe, RN, APN]

Tegridy said:

Also probably means not wasting money on tests that arent indicated

Absolutely. That would amount to shooting oneself in the foot.