OR Manager November/December 2021 - 13

OR business management
New value-based models allow for surgeon buy-in, cost savings
T
he growth of value-based healthcare
models is changing the way
physicians and hospitals provide
care. In value-based models, providers
are paid based on patient outcomes.
The " value " is derived from measuring
health outcomes against the cost of
delivering the outcomes.
This balancing act has now become
more achievable with new guidance
from the Department of Health
and Human Services' (HHS) Centers for
Medicare and Medicaid Services (CMS)
and Office of Inspector General (OIG).
With some of the regulatory hurdles
reduced, programs have the ability to
define and monitor value-based purpose
and activity through the alignment of
physicians and hospital teams.
A motivation
to move to an
alternative valuebased
gainsharing
agreement is that
money drives
performance.
From volume to value
Value-based enterprise is a new term
created by CMS in its December 2,
2020, Final Rule-Modernizing and
Clarifying the Physician Self-Referral
Regulations-to describe a contractual
arrangement among all types of healthcare
providers and with other entities
such as digital health companies.
The new rule, which became effective
in January 2021, gives great
flexibility for providers to participate in
value-based payment and care delivery
models as well as to provide coordinated
care for patients. The rule is
aimed at reducing regulatory barriers to
care coordination and transforming the
healthcare delivery system into one that
rewards value instead of
volume.
" Over the years, we
have talked about a
movement away from
volume to value, " says
Anthony Long, MBA,
FACHE, FACCA, CAAMA,
partner, Pinnacle Healthcare
Consulting, Centennial,
Colorado. " There
was a lot of discussion
" some organizations are going twice
as fast to catch up with delayed procedures. "
Anthony
Long,
MBA,
FACHE,
FACCA,
CAAMA
that we would never move in that direction,
but the reality is we are already
there, " he says. " We have moved from
fee-for-service, to fee-for-service that is
linked to quality, and finally to alternative
value-based payment models. "
Triple aim
Central to moving from volume- to valuebased
payment models is the Triple
Aim, a framework developed by the Institute
for Healthcare Improvement (IHI)
in 2007 to optimize healthcare system
performance. It was IHI's belief that
new healthcare designs must be developed
to pursue three dimensions:
* improving patient care through enhanced
care coordination and improved
patient outcomes (including
quality and satisfaction)
* improving health of populations by
improving coordination in healthcare
and by connecting care across multiple
providers (eg, hospitals, physicians,
and post-acute providers)
* reducing the per capita cost of
healthcare by holding providers
accountable for costs of total episodes,
not just one part.
Long notes that because of the
COVID-19 impact on scheduling, staffing,
and delayed procedures, a fourth
aim has now been added-access.
" What we have seen over the last year
and a half in terms of staffing, ORs
being shut down, and schedules curtailed,
the access issue has become a
major consideration for some organizations, "
he says. " And now, " he adds,
Whether the Triple Aim or the Triple
Aim plus access (ie, Quadruple Aim),
hospitals and physician practices are
leaning on these concepts to deliver
value-based care to their patients. In its
simplest form, it is care that results in
the best patient outcomes at the lowest
possible cost to the patient and the system,
he says.
Big picture
The underlying motivation for organizations
and physicians to move to an alternative
value-based gainsharing agreement
is that money drives performance.
Therefore, aligning financial incentives
should improve performance and results,
says Long.
The big picture goals of gainsharing
and value-based payments include:
* helping bridge the gap between feefor-service
and value-based payment
methods
* strategic alignment, collaboration,
and integration
* improving quality
* reducing costs.
" When we look at value-based agreements
in general, " says Long, " we really
are trying to pull together the big
picture. It's not just a matter of saving
money on a particular procedure or a
particular device, but what the organizational
and patient impact is overall.
In other words, what is the true 'value'
realized? " For example, he says, if an
organization saves on a device but readmissions
go up, the savings could be
wiped out.
The most common agreements Long
says he is seeing are:
* co-management, quality-based arrangements
*
OIG opinion-based gainsharing arrangements
*
Medicare arrangements, such as the
Comprehensive Care for Joint Replacement
Program and the Bundled
Continued on page 14
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OR Manager November/December 2021

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