You get what you pay for. For years, CMS paid for volume and that’s exactly what they got- lots of rehab, lots of tests, lots of specialists; lots of volume. But despite paying a lot for healthcare, our national outcomes remained mixed when compared to other similar countries, particularly in the areas of life expectancy, infant mortality, unmanaged diabetes and asthma.
No wonder CMS is focused on value-based payments. The concept is simple – value-based payment leads to value-based care. Why do providers need to care? What CMS does as a pilot many times finds its way into legislation that becomes our reality.
The SNF value-based program that was legislated in 2014 with the Protecting Access to Medicare Act (PAMA) came after CMS saw success with the Hospital Readmission Reduction Program (HRRP). Not only is CMS continuing to focus on outcomes driving payment, they are encouraging states to do the same when allocating Medicaid dollars.
Key Elements of Value-Based Programs
Key elements of a value-based program were outlined in a recent CMS memo sent to State Medicaid Directors:
- Level and scope of financial risk – Basically, this area addresses what providers are accountable for- all care or a carved-out portion? How much risk will providers assume?
- Benchmarking – How will the outcomes be measured?
- Payment operations – How will operators be assigned responsibility for which residents?
State Value-Based Programs
PointRight provides expertise on benchmarks and data aggregation to states so they can develop programs that rely on MDS data to measure outcomes. Working with state agencies and payors, PointRight was able to help create a collaboration that addressed the unique needs of the populations served by the state. [ Check out PointRight’s VBP work with New Mexico ]
With the collection of data from the new federal Patient-Driven Payment Model in about 31 or so states, keep your ears to the ground to listen for potential legislative changes and consider reaching out in advance to participate in pilot programs to get insights on what is happening in your state. Build a great Quality Assurance Process Improvement (QAPI) team that can handle any new initiatives that might develop.
To learn more about Value-Based Programs, check out our recent webinar recording below on the ABCs of VBP.