Shifting from Volume to Value Takes a Winning Team

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Shifting from Volume to Value Takes a Winning Team

Wednesday, August 19, 2015

Health care providers can no longer rely on fee-for-service (FFS) rate increases and payment policies to provide a sustainable source of revenue. An increasing percentage of available revenue is currently coming from what the Center for Medicare & Medicaid Services (CMS) calls "alternative payment models" (APM). The U.S. Department of Health & Human Services (HHS) has set a goal of tying 30 percent of traditional, or FFS, Medicare payments to quality or value through APMs, such as Accountable Care Organizations or bundled payment arrangements, by the end of 2016, and tying 50 percent of payments to these models by the end of 2018. These include performance incentive programs, risk sharing / bearing contracts, shared savings contracts, and other quality or cost-based contracting models.

These changes in contracting and payment policy are not limited to Medicare. In addition, many commercial and Medicaid plans are searching for ways to pay for value rather than quantity of services. Because of this, it is important that physicians act now to engage in quality initiatives and position themselves for financial incentives that increase future practice revenue.

Care management has surfaced as one of the strategies that physician organizations and practices can employ to support successful participation in the APMs. Multidisciplinary, centralized care management teams can be highly effective for managing a high-risk population. Members of such a team may include a nurse, pharmacist, social worker, and dietitian. Each team member has a different role based on their licensure. A registered nurse provides clinical support for patients related to education, medical neighborhood navigation, access, plan of care adherence, health related goal development, and coordination of care. A pharmacist can provide clinical support for patients experiencing barriers related to medication adherence, including medication reconciliation, comprehensive medication review, patient education, financial barriers, medication disposal, and physician support for poly-pharmacy issues. A social worker adds patient-focused support related to psycho-social issues that impact the patient's adherence to care plan. A registered dietitian can provide clinical support for patients with new nutritional requirements related to a health status change or an ongoing chronic condition requiring nutrition intervention.

This team effort offers a higher ability to proactively address patient-specific barriers to care plan adherence, which leads to a reduced incidence of expensive interventions, such as emergency department or inpatient visits.

Information is provided by Medical Advantage Group, a leading health care consulting and management company. Visit for more information.