What Is Value-based Reimbursement?

Many organizations in healthcare are moving towards value-based reimbursement models that reward value instead of volume. By transferring a large part of clinical and financial risk from payers to providers, value-based reimbursement models aim to lower costs considerably, enhance the quality of care, and boost efficiency.

Value-based reimbursement comprises various models. The effectiveness of the models should be evaluated based on market readiness. Value-based care systems must invest in resources to allow effective transitions and continuity of value-based care. Moreover, they need to realize that as they concentrate on wellness, inpatient volumes will drop, requiring cost-structure adjustments and added ancillary services to offset this decline.

The article explores value-based reimbursement in healthcare, value-based reimbursement models and how it is contributing towards lower healthcare costs.

Value-based reimbursement definition

Value-based reimbursement is the payment model for medical services that is taking the place of the traditional fee-for-service model for payers and healthcare organizations. The objective is to reduce rising healthcare costs by focusing more on quality of service than quantity.

This not only decreases costs but spreads financial risk among providers, while promoting coordination of care, disease prevention and better management of chronic conditions. However, clinical labs will find it hard to survive due to this model.

Difference between value-based care and fee-for-service models?

Fee-for-value is a capitated approach that requires paying the healthcare service provider an amount based on the services they provide. However, value-based care directly links performance on cost, quality and the patient’s experience of care. Value-based care puts the patient first and the emphasis is on quality rather than quantity..

Value-Based reimbursement Models

Pay-for-Performance (P4P)

Contrasted with different models, P4P has lower money related risk and requires less utilization of technology. While the provider is not obligated to reimburse monetary losses, it is still required to screen service quality and cost information through techniques like quality improvement with public reporting. P4P uses a fee-for-service structure, but value-based incentives and punishments might be experienced for not meeting quality and cost performance measures.

Payments of providers depends on the value and quality of service being provided. CMS would decide positive and negative payment adjustments based on evaluation with different estimates, for example, protection screenings, patient satisfaction surveys and Medicare spending for recipients. P4P could profit little from provincial practices that require time and assets to actualize innovation to effectively meet tracking prerequisites for value-based care.

Clinical episode/bundled payment

A bundled payment includes an assigned fixed sum for services per episode of care, irrespective of how many providers are involved. This wipes out the requirement for individual billing and considers providers responsible to empower coordinated effort and diminish duplications. If the expense is not exactly the assigned amount, the providers keep a segment of the savings. However, if the cost is more, then part of the revenue of traditional payment is lost.

This model can be hard to start and support because the provider may need to invest in IT resources to monitor spending and quality improvement measures. Moreover, changes in staffing models may need to be considered to assist Care Coordination efforts, which may not be repaid for related services to manage patient care.

Value-based reimbursement in healthcare depends on old benchmarks, so supporting these benchmarks can be troublesome once they are low, for they should stay low for shared savings. This model is more qualified for healthcare facilities with high rates of healthcare spending, admissions, and asset use to provide more opportunities to progress to acquire more savings.

Shared savings/Risk model

The shared savings model gives a higher level of monetary reward than the Pay-for-Performance model. It reimburses equivalent to fee-for-service, yet providers are paid depending on cost and quality performance. However, if the provider can decrease costs under the payer benchmark, they can share a portion of the savings.

Numerous providers enter a shared risk model through an ACO. The financial risk makes them answerable to ACO. A disadvantage of the risk model is that it gives more opportunity for financial rewards than shared savings. The budget for foreordained quality performance levels must be met, or the provider must cover part or all the cost.

Capitation/Global Payments

Capitation models pay a fixed sum for every patient, per unit of time, which is repaid to the provider for services. Most incorporate value-based care benefits and punishments based on quality and cost. If the provider generates medical care savings they can keep it, but if they can’t offer services below the assigned amount, then the provider is answerable for the loss in revenue.

A partial or blended capitation agreement pays providers a single monthly fee that covers set services such as laboratory services or primary care. Other health care is reimbursed with a fee-for-service model. The advantage of prepaid reimbursements is that the provider can utilize this money to execute methods for improving patient care.

Global payments are a single fixed payment for all the patient’s healthcare services such as primary care, hospitalization and specialist care, and includes full financial risk for quality care and healthcare spending. This is paid per member, per month, and can be invested to improve efficiency, but the provider bears full financial risk for any excess cost.

What are the benefits of Value-Based Care?

1. Low healthcare expenditure.

Dealing with a persistent illness or condition like disease, diabetes, hypertension, COPD, or weight can be expensive and tedious for patients. Value-based care models help patients recuperate from sicknesses and wounds at a faster pace and evade chronic disease in any case. Thus, patients face less doctor’s visits, clinical tests, and procedures, and they spend less cash on doctor prescribed medicines as both short term and long term health improve.

2. Efficiencies and increased patient satisfaction.

Hospitals and physicians may be required to spend more time on prevention-based services, hence, time spent on chronic disease management will be reduced. Since the focus is on quality treatment and not on volume, the service providers will not be responsible to bear financial risk because they will be rewarded based on this module.

From the patient’s perspective, you can expect better and quality treatment as the service provider will be eager to treat more patients. Hence, chances of quick recovery will increase leading to a healthier life.

3. Decreased risk for payers.

The overall risk of payment is lowered considerably with a larger patient population. Healthier population in society will lead to fewer claims that result in a lesser drain on the payers’ investments and premium pools. Value-based reimbursement model also allows payers to increase efficiency by bundling payments that cover the patient’s full care cycle.

4. Benefit to the suppliers.

Apart from patients and doctors, the suppliers also benefit from this initiative. They will now be able to arrange their products according to patient outcomes. There is a sharp rise in the price of prescription drugs, something that is extremely expensive for some people. It is believed that the overall cost of the drugs will get lower if the suppliers can align their services to positive outcomes. The healthcare industry in many countries who are working towards value-based care reimbursement has asked drug manufacturers to set the medicine prices according to the actual value to patients. This is more likely to become a convenient option for them and the patients because patients will get them at a lower price than before.

5. Healthier society and reduced overall healthcare spending.

Value-based care model makes sure that less money is spent helping people manage chronic diseases, expensive hospital services and medical emergencies leading to a healthier society.

Future Prospects for Value-Based Reimbursement in Healthcare

The initiation of value-based care reimbursement has changed the way in which hospitals and physicians operate. Numerous nations have additionally thought of initiating health care delivery models with a team-oriented approach. Patient data is easily available on cloud storage facilities so that the team of doctors can retrieve data quickly if the patient is in critical condition and needs immediate medical assistance.

The change from the traditional fee-for-service to value based care will not occur rapidly. However, the transition has been smooth in countries that have already embraced this program. The goal to reduce healthcare costs while improving quality care will lead to a healthier society. As the healthcare industry continues to grow and evolve, healthcare facilities that are still oblivious of what is value-based care reimbursement will slowly start to see the changes around them as the others go through the transition. It may hit their profits initially, but the long-term benefits of this module will see them earning.