Will the Change to a Value-Based Care Model be Disruptive?

A 2018 study from the U.S. Department of Health and Human (HHS) revealed that more than one-third of healthcare payments are now tied to value-based care.

Those who have been hesitant to move to this new model may assume that an overly complex system for quality reporting in value-based care models is required. This would, therefore, require excessive amounts of time and manpower which would lead to increased costs.

We have seen how value-based care payments are reshaping the entire healthcare industry and through our decade of experience at Enlace Health, we know that there is a commitment to achieving the promise that the value-based care model promises.

The Industry Shift To Value-Based Care Has Prompted Regulatory Changes.

Ongoing efforts to reform healthcare finance and delivery have led to changing administrative requirements.

The Stark Law (or “self-referral law”) was designed under the fee-for-service model. The goal was to prevent healthcare fraud. However, as more groups moved toward a value-based care model, they found that complying with the Stark Law was arcane to all except specialized attorneys or expensive compliance consultants.

Medical groups called for value-based care reforms to update laws such as the Stark Law, align with quality measures, and implement more consistent waivers and rules across value-based care programs.

As stated by the American Medical Group Association (AMGA) President and CEO, Jerry Penso, MD MBA “Our members are treating patients through delivery models that hold them accountable for the cost and quality of the care they provide. These models by design do not contain the same misaligned incentives seen in the fee-for-service environment, and Medicare’s rules and policies need to recognize and account for this difference.”

The American Medical Group Association (AMGA) commented that “providers that participate in these value-based arrangements should enjoy a consistent regulatory framework and have access to the tools that support their ability to deliver the highest quality of care to their patients.”

CMS has already taken action on the Stark Law in order to bring the outdated regulations up-to-date with the 21st century and the shift towards value-based care. In November 2020, CMS announced that they “finalized changes to the outdated federal regulations that have burdened health care providers with added administrative costs and impeded the healthcare system’s move toward value-based reimbursements.”

Caring For The Providers Who Care For Their Patients

Increasingly, providers have been overwhelmed by tasks that do not appear to add value to patient care. Several studies have revealed how the increase in administrative tasks have led providers to feel emotionally exhausted and burned out. Much of the administrative tasks have evolved from outdated models and do not reflect the capabilities of technology to gather insights from significant volumes of data.

Both payers and providers have expressed concerns that a pay-for-performance model will add even more administrative costs and complexity.

However, that is the opposite of the goal of the movement toward value-based care. In a fee-for-service model, payers reimburse providers for each service rendered. An office visit gets one payment, a blood test is another payment, and an MRI is yet another payment. This inherently becomes an abundance of redundant administrative time. On the other hand, value-based programs consolidate the reimbursement to cover an entire episode of care. From the insurer’s perspective, this is very simplistic approach. On the other hand, from the contracting provider’s side, having to disseminate one lump sum to affiliated downstream providers can be intimidating. This is where industry experts, such as Enlace Health, have developed specific systems to administer the financial transactions associated with episodes of care and other consolidated value-based payment models. Enlace Health’s Claims Payments & Claims Administrator promote efficient value-based care claims administration on behalf of clients.

Another concern is how the responsibility of manually reporting required quality measures multiple times for each payer and program will prevent smaller practices from participating in value-based programs. In addition to the standardization of quality measures, the National Academy of Medicine recommends a team-based focus for care management of the patient, which is a core construct of value-based programs. Collaboration between clinicians improves patient and provider satisfaction while improving quality and patient outcomes.

Not only will a switch to a value-based care model decrease administrative tasks allowing providers to spend more time caring for their patients, but the insights that can be gleaned from the volume of data also enable the medical profession to continuously identify ways to improve the quality of care.

Change is never easy or seamless. The effort to change an entrenched health care system that millions of people rely on is truly extraordinary. Each step along the way there will be obstacles to overcome such as outdated laws or redundant information. At Enlace Health, we have witnessed that rewards of moving forward promise to be greater than the tasks required to get there. We know that this is a time of extraordinary change, which is why our software was developed to be agile and our team of experts is ready to meet the needs of our clients, wherever they are on the journey.


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CMS Announces Historic Changes to Physician Self-Referral Regulations

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