Foundational elements for switching to value-based care

It’s not a simple transition, impacting all healthcare touch points, from IT to clinical.
By Matt McElheny
12:58 PM

The recent HHS mandate, which has set explicit goals for alternative payment models, requires 50 percent of Medicare payments to be based on performance by the end of 2018. This means that many payers and providers will need to change processes sooner than originally planned, so it’s no surprise that value-based care has risen to the top of industry discussions.

The high-level goal of this alternate payment model is to fix unnecessary expenses and inefficiencies in our healthcare system, all while improving quality and consistency measurements – a win-win for all payers, providers and patients involved. Tying reimbursement to outcomes can lead to better patient recoveries, more predictable costs for all parties, higher prescription adherence rates, fewer readmissions and fewer medical errors, among other benefits.

Still, many remain resistant to change. It’s not a simple transition, impacting all healthcare touch points, from IT to clinical. Leaving behind fee-for-service requires a change in tooling, focus, and mindset. Rather than thinking singularly, payers and providers need to consider a patient’s end-to-end healthcare experience.

Fortunately there are key tools and procedures available that can help ease the transition towards a holistic, predictable and outcome-based approach to managing healthcare.


Addressing F.U.D. -- fear, uncertainty and doubt -- is a necessary first step. Present with any change, but certainly for one this vast, hesitation should be expected and responded to with peer-to-peer communication from a knowledgeable and trusted partner. Having advocates on staff that are proactively educating and encouraging process and quality improvement opportunities for physicians and office staff will help create positive clinical impacts, reimbursement changes and quality improvements. This will ultimately ease the transition. Transparency around changes, reasoning, and results will help mitigate resistance around the adoption of bundled payments.


Managing the full patient experience rather than individual doctor visits and services can be difficult to wrap your mind around. You must consider potential complications, quality measures and localized population needs. In order to effectively make the switch, you’ll need the proper underlying analytics to help. Robust and relevant analytics can assist with understanding the full picture, showing the real end-to-end costs of caring for an individual and present measurable opportunities for improvement. Healthcare analytics have finally matured to allow laser focus on examining processes, measuring outcomes, and presenting opportunities for practice transformation until healthcare delivery becomes as successful and efficient as possible.

Engaging with an analytics provider and training employees to longitudinally look at all possible encounters and intervention points and relate them back down to the patient care level is necessary. The proper tooling and skills training can help you quickly access the quality measures that are most effective and actionable and subsequently see measurable improvement over time. Having the proper data at your fingertips can help identify clinical variations, utilization rates, and check against your internal and external benchmarks, giving you insights around what needs to be altered and which changes were beneficial.

Patient Tooling and Education

In order for bundled payments to work at their optimal level, we as an industry need to provide patients the real-time information they need to properly utilize healthcare. To stay within episode definitions, they should have a firm understanding of their care path. Multiple studies have consistently shown that a majority of patients cannot accurately articulate their complete diagnosis or continuation of care instructions. Patients do not understand the impacts of self-referrals, going outside their optimal coverage networks, forgetting to fill prescriptions, or skipping follow up appointments. All interconnected, patients’ actions play a direct role in quality and outcome measurements. Teaching patients the importance of staying within recommended care paths will be essential, and providing effective tools and patient portals for both them and their caregivers will be key to achieving a successful transition.

Being conscious of the fact that patients don’t always read or understand paper materials provided, some physicians are hiring on-site nurse practitioners to focus on direct and in-depth patient outreach and education. Ensuring that patients and caregivers understand the big picture, have the support they need after procedures, are aware of risks and costs, and that they follow treatment plans, these embedded in-practice nurses play a critical role in the successful switch to value-based care.

We’ll gain additional insights as the latest mandate is implemented, but these three foundational elements will help payers and providers rebuild their systems, gain support, adjust measurements and more easily adopt a value-based care model.