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Navigating Value-Based Care: Tips From the Field

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For more than a decade, federal legislation and programs at the Centers for Medicare & Medicaid Services (CMS) have aimed to transform health care delivery and payment from a volume- to a value-based system. With varied names—value-based purchasing, value-based payment, pay-for-performance, pay-for-quality—all of these initiatives emphasize incentivizing health care providers to improve the quality of care delivered to Medicare and Medicaid beneficiaries.

Our team at L&M Policy Research (L&M) has a front row seat to different value-based arrangements through our work on program evaluations and payment models for CMS and other agencies. We have seen how some providers are able to reap rewards for themselves and their patients.

Whether your organization already has value-based contracts (VBC), is contemplating specific arrangements, or is still preparing to engage in value-based care, here are our tips and questions to consider:


Tip #1: Follow the money.

Look at your spending patterns—focus on high-cost conditions and services and ask:

  • Which clinical condition(s) generate the highest costs?
  • Are some providers ordering more tests than others?
  • Are high-cost services adding value? Improving patients' health?
  • What unmet social needs are contributing to higher costs?

Tip #2: Leverage your data.

Data linkages can enrich what you know about your patients. Look beyond claims to integrate sources of information that tell your patients' health care stories.

  • Link clinical data from EHRs to claims to identify patients who may be high risk/high need.
  • Set up alerts from hospitals and/or a local health information exchange (HIE) so you know when your patients are accessing services across settings and providers.
  • Identify which patients could benefit from proactive outreach, communication and care navigation; find a "Community Resources Inventory" and connect your patients to additional supports.

Tip #3: Know your metrics.

Look at which domains of quality are emphasized in each of your VBC arrangements — it may differ from one contract to another.

  • Assess your performance over time and relative to benchmarks.
  • Focus on metrics where you think you can improve; start with the "low-hanging" fruit.
  • Determine if documentation or reporting are affecting your performance scores.
  • Develop and implement an improvement plan for these metrics.

Tip #4: Work as a team.

Delivering patient-centered, high-value care takes a team. Assess whether you have the right members on your team and pinpoint the gaps.

  • Is everyone working at the top of their license?
  • Where are patient needs going unmet or where is staff over-extended?
  • How would additions to the team fit in your organization's workflow?
  • Are there revenue sources or budget to support new team members?

Tip #5: Fill in the gaps.

Determine the facets of your VBC strategy. Are there key tools or approaches that will support achieving value and reducing unnecessary costs? Here are common areas we've encountered:

  • Emergency department use. Are your patients showing up at the ED for routine complaints? Do you have a follow-up process after discharge? Can you add evening/weekend appointments or a nurse call line?
  • Patient engagement. How do you support patient activation and self-management? Would email or text outreach or reminders help? Do you have partnerships to support patient transportation needs?
  • Provider engagement. How do you involve providers in your improvement plans and VBC strategy decisions? What ongoing communication channels do you use?
  • Managing care transitions and referrals. How are you notified when a patient's care setting changes? What processes do you use to track and manage referrals? Will you develop a preferred provider network for referrals?
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