For years the Government, commercial insurance providers and even the general public have been trying to control healthcare costs. Regardless of politics, in the rapidly changing healthcare landscape, payers are asking providers to shift from volume-based care (fee for service) to a value-based reimbursement structure (value based service) with a population health approach. This evolution toward value-based reimbursement benefits the patient, the healthcare provider and the payer. Value-based reimbursement encourages healthcare providers to deliver the best care at the lowest cost. In turn, patients receive a higher quality of care at a better value.

In 2011 the U.S. Department of Health and Human Services (HHS) released new rules under the Affordable Care Act (ACA), aimed at helping doctors, hospitals and other providers better coordinate care by way of Accountable Care Organizations, or ACOs.

Today, with the changes in Administration the HHS approach has been turned upside down. Anything associated with Obama is “bad”. Many of the initiatives started under the Affordable Care Act are being trashed, especially when Tom Price was Secretary of HHS. He’s gone and replaced by Alex Azar. Many experts who follow these things are optimistic that Azar will be more balanced.

Accountable Care Approach to Value Based Service:

Value based service is not a new concept, but with costs rising and patient outcomes largely stationary, a new emphasis was being placed by the previous Administration as well as commercial insurers. One area of focus was on a concept that been around for years, before the Affordable Care Act and that was Accountable Care Organizations.

Accountable Care Organizations (ACO) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients. The benefits could also be realized by insurance companies and large employers.

An accountable care organization (ACO) is a healthcare organization that ties payments to quality metrics and the cost of care. They use alternative payment models, normally, capitation. (Capitation is a payment arrangement for health care service providers such as physicians or nurse practitioners. It pays a physician or group of physicians a set amount for each enrolled person assigned to them, per period of time, whether or not that person seeks care.) The organization is accountable to patients and third-party payers for the quality, appropriateness and efficiency of its services.

Alongside the Centers for Medicare & Medicaid Services (CMS) -backed plans, commercial health care insurers also began offering risk-based contracts to providers. One such program, established long before the CMS initiatives, was the Blue Cross Blue Shield of Massachusetts Alternative Quality Contract (AQC), which ultimately served as a model for payment reform.

As of 2017, one of the foremost experts in ACO research, Leavitt Partners, is tracking 923 ACOs including the various types shown below.¹

Most commercial risk contracts include similar combinations of quality incentives, shared savings, full capitation and small budget adjustments for medical inflation, but variety in the contracts and frameworks has surfaced. Some contracts have moved to partial capitation (also known as bundled payments), retainer agreements, in-kind services and subsidies provided by payers, or have limited themselves to upside-only pay-for-performance incentives.³

Episodic Approach to Value Based Service:

In addition to the more holistic ACO approach, the Centers for Medicare & Medicaid Services (CMS) introduced a limited initiative to both reduce Transactional Care Management (TCM) costs and improve patient outcomes. This initiative is called the Bundled Payments for Care Improvement (BPCI). As of October 1, 2017, the BPCI initiative has 1191 participants (Health Care Providers) in Phase 2, comprised of 252 Awardees and 939 Episode Initiators. The emphasis on BPCI has faded somewhat under the current Administration.

These medical conditions were called Episodes of Care. There are many different episodes but most involve orthopedic, pulmonary, and cardiac patients.

Under this BPCI approach, the Health Care Providers (HCP) are paid a fixed amount of dollars for the procedure and the recovery, capitation. The new financial liability associated with the recovery period (normally 90 days) presents the HCPs a new challenge. As a result, many medical groups have been evaluating better ways to mitigate the recovery period costs.

Traditionally doctors require the patient to come back into the office for periodic visits. Additionally, they may ask nurses to visit patients in their home or temporary residence. To assist with monitoring a patient’s recovery, HCPs are also exploring various telemedicine options.

To date, finding a consistently effective solution for BPCI has proven elusive; however, a success story is emerging in Greensboro, NC.

After learning about bundles by participating in the BPCI program, four joint replacement surgeons realized joint replacement bundles would work well in the commercial outpatient setting. The physicians created Valere Bundled Solutions and learned how to become their own convener. In this model, they made all clinical and financial decisions within the bundle. They took all the responsibilities, so they could be in total control of the entire episode of care for their patients.

They have completed almost 100 joint replacements in the first year with a 100 percent patient satisfaction rate, a zero percent readmission rate and a zero percent complication rate.

Serving as the convener has also made a significant impact on their bottom line.²

Under this model, the physician takes all the risk and thus keeps all the reward. In addition, the entire process is simpler and more affordable for the patient. Once the patient has paid their deductible on the front end, there is no further co-pays or bills during the entire episode of care.

By acting as convener, the physicians cut out the middleman and negotiate downstream contracts for all of the parts of the bundle [facility fee, surgeons, anesthesia, implants, recovery and rehabilitation].

Health Care Delivery Systems Impact on Value Based Service:

While there are positive trends with both ACOs and BCPI participants, there continues to be variation in performance. This reinforces the conclusion that payment reform alone is not sufficient to meaningfully improve quality and lower costs, but that changes in health care delivery are also required.

However, reconfiguring care delivery is not simple. Delivery reform requires redesigning systems, infrastructure, and processes, investing in health information technology, creating new partnerships, substantive changes in clinician and administrative tasks, and many other significant challenges. One of the most difficult challenges is the cultural redesign required at all levels of the organization, from leadership to the individual clinicians. From interviews and surveys gathered from hundreds of ACOs, we have consistently heard that delivery reform is a monumental logistical, financial, and technical hurdle. The time to effect this change is measured in years, not months.

Research Summary:

Summing up the years of research in the trend towards Value Based Service yields at least three important take-a-ways.

1. The longer an organization works towards Value Based Service, the better the results.
2. The smaller the organization, the more likely they are to achieve quicker, more effective results.
3. If progress in payment reform is not matched by progress in delivery reform, this will cause ACOs to leave the voluntary program and revert to non-value-based models.

Potential Healthcare Delivery System Reform Suggestion:

Perhaps it is time to consider a cultural alternative to healthcare delivery that involves non-medical, hourly workers.

Is there a useful process to collect information from non-medical workers that reduces cost and improves recovery outcomes?

It could be as simple as the patient self-reporting using a structured process. For the more significant episodes, the data collection may require caregiver reporting, either by family members, volunteers or even paid caregivers.

During the recovery period, these non-medical individuals will see the patient much more frequently than the professionals. They see the patient on a daily basis, and can report changes in condition in a timelier manner than the infrequent professional visits.

As you might suspect, medical professionals have concerns about collecting information from these sources.

• Can they rely on this type of information? – Harvard Medical School (HMS) recently reviewed the preliminary data from a home caregiver pilot program³. In that pilot, caregivers were tasked to report any “changes in condition” with their care recipients. The HMS review pointed out many successful outcomes, including “relatively few false positives”.
• Will the use of information from non-medical individuals increase the Health Care Provider’s (HCP)’s liability? The recommended solution does not change, in any way, the guidance or instructions provided by the HCP. Specifically, the nothing in the solution alters the doctor’s duty of care.
• HCPs rightly claim that all we need is more information! – Currently with all the digital systems, medical professionals can be easily overwhelmed with information. It is becoming increasingly difficult to keep track of volume and isolate the information that truly affects patient recovery. (It is easy to get lost in a HCP’s EMR system. That is one of the benefits to having a simple, separate system.)

Home Care LINK (HCL) has developed an approach for every caregiver to record changed condition observations. These observations are automatically sent to our cloud-based server following each observation. These time-phased, secure reports are immediately available to all authorized users.

Home care LINK also features “medication reminders”. This feature focuses on loading a simple pill box/organizer and monitoring a patient’s usage. Results are recorded and sent.

Each HCL observation is prioritized as normal or critical. If a critical observation is recorded, automatic alerts are sent (text or email) to whomever the case manager has designated.

Essentially, HCL is a telemedicine variation that is simpler and much less expensive. Home Care LINK costs less than $40.00 per month plus that price is all-inclusive – the software, the digital tablet, and the data plan to transmit the collected data. No additional equipment or connections are required.

Many professionals and surveyed family members believe the concept of using “hourly non-medical “ workers has great promise to improve home health care delivery. However, going from concept to implementation still remains to be proven.

This is the wave. Now the tough part; how to catch it? Episodic Care is perhaps the most immediate way, but the broader Accountable Care approach may offer even greater long term benefits.

Implementation scenarios and business models need to be tested to evaluate whether Home Care LINK can deliver the expected potential. Below are just three, but there may be many more.

Scenario 1 – The Health Care Provider (HCP) recommends a Home Care Agency (HCA) that is Home Care LINK “certified”.

• The Health Care Provider –
• The HCP prepares a list of all the HCAs in the area that are HCL certified
• For each discharged patient, the HCP creates the specific conditions they want non-medical caregivers to monitor.
• The Home Care Agency –
• They become Home Care LINK certified.
• They train their caregivers to operate HCL.
• They work with the patient’s family to pay for the service.
• The HCA performs the required Home Care LINK setup.
• The HCA’s care coordinator (normally a nurse), receives and filters the reported changing conditions and communicates that information to the HCP as appropriate.

Scenario 2 – The Health Care Provider’s recovery staff sets up Home Care LINK and the data collection is performed by the family or other caregivers.

• Many HCPs have a specific group that is responsible for monitoring the recovery process. This group would include the overworked case manger and commonly a separate nursing staff.
• In this Scenario, the nursing staff would setup Home Care LINK “changed condition” reporting to correspond with the specific episode recovery for each patient. The actual data collection would be performed by the family or an outside caregiver. The reporting, including alerts, would be sent to the HCP’s nursing staff.
• The payment for HCL would be included in the patient’s bill for service.

Scenario 3 – The patient’s family buys and sets up Home Care LINK.

• Health Care Provider –
• Recommends the use of Home Care LINK.
• For each discharged patient, the HCP creates the specific conditions they want non-medical caregivers to monitor.
• The family Care Coordinator –
• Pays for the service
• Performs the required Home Care LINK setup.
• Filters changed condition reports and calls the HCP as necessary.
• In coordination with Oversight Inc. they help train all caregivers.
• The family’s caregiver –
• They collect the data as required.

Benefits:

• Observation windows are more comprehensive.
• Timeliness is significantly improved.
• Alerts and Reports are customized to each patient.
• Costs may be significantly reduced.
• No requirement to technically integrate into the existing EMR system.
• In many cases, the patient’s family pays for the caregivers and the HCL service.
• The data collection device is an inexpensive Android tablet.
• The potential to improve efficiency and reduce financial liability is significant.
• By reducing patient recovery issues, HCP’s comparative ratings may rise.

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1. “Where are ACOs Headed?”, by de Lisle and Bowen, Leavitt Partners website, July 14, 2017.
2. Physician driven bundles – How Drs. Steve Lucey, Frank Aluisio, Matt Olin and Frank Rowan took control of the bundle”, by Eric Oliver, Becker’s ASC Review, January 22, 2018.
3. “Preliminary Data on a Care Coordination Program for Home Care Recipients”, The American Geriatrics Society Journal, August 2016.