The Road to Value-Based Care

The Road to Value-Based Care

Value, much like beauty, is in the eye of the beholder. It’s the new destination for healthcare that lies at the intersection of quality, cost efficiency and consumer satisfaction. Depending on your role in the healthcare system, one of these three topics may have a higher priority in defining value. Still, all three must be considered on the road to value-based care.

More specifically, the term value-based care describes new efforts within our evolving healthcare delivery system. The current “fee-for-service” model (paying for care in silos and rewarding volume) is not sustainable for our economy. As a result, we must reimburse doctors, hospitals and other healthcare providers for the quality, or the value, of the care they provide.

The path to this intersection is one less traveled. Healthcare is moving into a new era; however, new does not mean unfamiliar. As we move forward, we must learn from the past, take advantage of new technologies and encourage new ideas.

Our strategy is the vehicle we use in our approach. It must be steady, persistent, flexible and place “risk sharing” in the driver’s seat.  Every player in the health care system must take responsibility of the wheel. That includes insurers, doctors, hospitals, employers and patients. We must all accept risk and be accountable for the decisions we make because they affect everyone else.

One of the most important ways to ease the stress that comes from that risk is to work as a team. All key stakeholders--patients, physicians, hospital systems and insurers—need to be on the same page. We can teach each other about our perspectives by being transparent. In doing so, we can find our strengths and weaknesses. We can also empower each other to focus on areas that make the biggest and best difference. Of course, we must first learn to trust that we’re all working together on the same team and we all have the best intentions for everyone involved.

BCBSTX not only recognizes this need, but has already begun the journey. Over the last several years, we’ve developed, implemented and monitored a variety of value-based care programs such as Bridges to Excellence, Accountable Care Organizations (ACOs) and Episode of Care. These programs have shown BCBSTX’s dedication to making necessary changes to our healthcare system.

Bridges to Excellence (BTE) pays incentives to physicians recognized for excellence in managing diabetes, heart disease, asthma and inflammatory bowel disease. To date, more than 38,000 members in Texas have been treated through the BTE program.

ACOs have evolved into a delivery and payment model that gives independent physician practices and large hospital systems the ability to enhance their relationship with patients. An ACO is formed between medical groups and health insurers. It allows both parties to focus on their strengths while also supporting weaknesses. Medical groups focus on population health and care delivery while payers help with data analytics around utilization costs and claims history. The model has gained popularity and BCBSTX now has 25 ACOs throughout the state of Texas.

The Episodes of Care program is a model that pays providers a set amount for all services related to a specific episode of care. We define an “episode” as a set of medical services surrounding a clinical condition throughout a pre-defined period. This creates value by allowing physicians the control to deliver the care at the location of their choice. Because their compensation is a set amount, they are motivated to consider the cost of the facility when making their decision. In addition, a “care continuum” is formed around this particular diagnosis. That’s basically a system that guides and tracks patients as they work their way through the health care system. Providers quickly realize that it is critical to communicate with each other and the patient to be successful.

One thing is certain when it comes to health care value: change is on the road ahead. We must all decide to participate in the solutions because the problem can’t be solved by one individual or one entity.  It’s easy to say that we want to be a part of the team, but it’s much more challenging to show it.

Presented by: Bharath Thankavel, MD, Medical Director, Value Based Care

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