Transitioning from Fee-for-Service to Value-Based Care

The United States healthcare system is undergoing an aggressive reform push to eliminate inefficiencies and maximize existing scarce resources. The shift towards value-based care is one of the highlights of this healthcare reform agenda.

Traditionally, healthcare providers in the United States were primarily motivated by the volumes and profits, ignoring the nature and quality of outcomes. Today, healthcare providers are encouraged to seek resource efficiency while improving the quality of care and patient outcomes.

Value-based care is defined by a philosophy to expand access to care and create an optimal healthcare system. It differs from fee-for-service in that it redefines the principles that guide medical practice. Specifically, value-based care calls attention to aspects of care such as quality and proactive interventions that help manage the excesses typical to the health system.

For instance, value-based care is founded on the realization that reactive health interventions are expensive and result in poor care outcomes because diseases are at an advanced stage. Value-based care encourages proactive and evidence-based interventions that improve costs and patient outcomes. In addition, value-based care has been shown to compel healthcare providers towards inter-professional collaboration and the integration of care practices.

Despite the vast advantages envisioned from the transition to value-based care, there is a need to invest in resources that enable the model. One of the challenges to value-based care is the presence of resource limitations that challenge the implementation of tools critical to value-based care’s success. For instance, aspects of value-based care such as medical homes, accountable care organizations, and capitation rely on sufficient financial and human resources access.

These challenges are made more difficult by the expected shortage of nurses who make up the largest workforce in healthcare. According to the US Bureau of Labor, an estimated 11 million nursing professionals are needed to avert a looming shortage. The Association of American Medical Colleges has also raised similar concerns indicating that by the year 2034, the health industry could contend with physician shortages as high as 124,000. These concerns create the need for state and non-state actors to step in and help ease the resource deficiencies that challenge the industry.

Despite the foreseen challenges, value-based care has numerous advantages. First, the model’s proactive nature means that disease states are identified before they advance to more complex stages. This way, value-based care helps to minimize patient suffering.

Again when healthcare providers prioritize cost-efficient care strategies such as prevention, there are fewer resources used in the course of care provision. This efficiency substantially improves the bottom line by eliminating resource wastage in re-admissions and high drug subscription costs. Most importantly, value-based care aligns with healthcare’s original mission to heal and improve society’s wellbeing. The shift to value-based care re-imagines the healthcare industry’s mandate by prioritizing value and quality over profit maximization.

Since value-based care seeks to operationalize processes and systems that improve patient outcomes and facilitate the efficient use of healthcare resources, it will help reverse the inefficiencies created by years of a health system founded on profit. While some might view value-based care as the beginnings of a social healthcare system, the trade-offs in social value are evident.

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Understanding Integrated CKD and ESRD Programs

Patients with Chronic Kidney Disease (CKD) and End-Stage Renal Disease (ESRD) are continuously faced with increasing costs and demanding treatment plans that make treatment an overwhelming experience. This becomes more difficult when a patient has to deal with different physicians from different facilities who do not have the means to communicate with each other concerning a patient effectively.

The transition from one healthcare to another is costly for kidney patients and may result in poor health outcomes. The progression of patients from the advanced CKD stage to ESKD is also linked to clinical instability and prolonged hospitalization. The move from one health facility to another as a patient seeks medical attention for different conditions also presents a risk of delayed treatment in a situation requiring immediate attention. These challenges present the need for coordinated care to help improve patient care quality.

Luckily, the introduction of integrated care that offers a holistic approach by considering various factors that make up treatment plans for kidney care is a promising solution. The integrated care model is based on value-based care where a healthcare provider is paid as per the patient outcome rather than how many services were administered. It also involves addressing a patient’s healthcare needs in one place and offering a better patient experience as it saves them from the logistics burden and offers coordinated care.

The integrated care is a welcome move considering that patients with advanced CKD also experience co-morbid (additional conditions) diseases, such as diabetes and cardiovascular diseases, that require treatment, adding to an already mentally and physically stressful treatment plan. Each disease requires a patient to visit different doctors and even have several care plans. The needs for End-Stage Renal Disease (ESRD) patients are even more complex as they also require frequent dialysis treatments to sustain life.

However, with integrated care, disease management becomes convenient. A good example of an integrated program for patients with kidney failure is the ESRD Seamless Care Organization (ESCO), a model whereby Medicare assigns a patient to an ESCO based on facilities where they go for dialysis. ESCO takes responsibility for all treatment costs for an ESRD patient. The ESCOs are part of the Comprehensive ESRD Care Model established to develop better ways to improve the care given to patients under Medicare.

Aside from ensuring reduced cost for healthcare costs, integrated kidney care serves to educate the patients on treatment options and other related information, helps avoid unnecessary hospitalization, and helps to lower the rate of unplanned dialysis starts. This has been made possible through actionable data analytics that physicians can use to make better-informed decisions when handling patients.

Since an integrated care model addresses the needs of the kidney patients in one location and reduces the logistics burden, a patient will receive quick care and hence better health outcome. Through integrated care, it is possible to maintain continuity and consistency in-inpatient medical records making it possible to track patient treatment and progress, which improves the overall patient experience.

Whereas traditional fee-based services may lead to prolonged treatments as physicians seek to maximize payments, integrated care focuses on the outcome of a service. Thus, combining integrated care with value-based care contributes to innovative solutions specific to different patient needs.

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