The Ultimate Guide to Value-Based Care

According to the Centers for Medicare & Medicaid Services, healthcare spending in the United States grew 4.1% in 2022 alone. Total spending hit an enormous $4.5 trillion, which breaks down to roughly $13,493 per person. 

However, it’s important to note that part of the reason why healthcare costs are on the rise is because the price one has to pay for effective healthcare is rising, too. As healthcare itself gets more expensive, people tend to go to the doctor less frequently. They’re certainly not participating in the type of proactive treatment they need to address a small problem before it has a chance to become a much bigger (and potentially deadlier) one. 

Another study indicated that poor adults are literally five times more likely to be in poor or fair health than those with incomes above 400% of the federal poverty level. These lower income people have dramatically higher rates of issues like heart disease and diabetes. 

People with more money tend to have access to better healthcare, and themselves are healthier as a result. When you also consider the fact that wealth inequality in the United States has only grown worse  over the last few years, you begin to see why this is a problem with potentially dramatic long-term implications. 

From that perspective, one might argue that the current healthcare system isn’t as effective as it can be when it comes to treating patients and statistics like those outlined above go a long way towards proving it. That, in essence, is why value-based care has become so popular in recent memory. But what is it, how does it contrast with the current fee-based model of healthcare, and what technologies are needed to allow as many people to embrace it as possible? The answer to questions like those requires you to keep a few important things in mind. 

What is Value-based Healthcare?

As the name implies, value-based healthcare associates the amount of money a healthcare provider earns with the actual, tangible results they deliver. Essentially, it’s a way to make sure that provider pay only goes up as healthcare quality and equity do the same. 

In a larger sense, it’s seen as a way to hold providers more accountable for what they’re doing on a daily basis. If providers are known for “treating the symptom instead of the disease,” so to speak, their patients wouldn’t be showing meaningful improvement. Nobody would actually get better. Once they start to achieve more positive outcomes, their own earning potential increases. 

Therefore, they have at least a financial incentive to not only do the best that they can, but to innovate and try to do better as well. 

Note that this is all in contrast to a more traditional “fee for service” model. Here, healthcare providers are getting paid based on the number of services they perform. If a doctor performs the same surgical procedure 1,000 times, they make a certain amount of money regardless of whether patients are actually healthier afterward or if the issue that necessitated the surgery had been solved. 

At this point, the incentive isn’t to achieve the highest possible level of patient care. It’s to order as many services as possible.

The Major Benefits of the Value-Based Care Model

The Benefits for Patients

For patients, one of the most immediate benefits of the value-based system is one of cost-savings. Under the fee-based model, care providers are not only incentivized to recommend procedures that someone might not expressly need but to prioritize the more expensive ones as well. 

With value-based care, providers are more accountable for cost as it relates to service quality. This has a tendency to drive the cost of care down, without sacrificing quality of care along with it. 

In an over-arching sense, the biggest benefit of value-based care is that the population becomes far healthier as a whole. When providers are forced to prioritize quality of care, you tend to achieve better outcomes wherever possible. People aren’t treating certain conditions indefinitely – in many situations, they’re cured. 

Because of that, and thanks to declining costs, people take a more proactive approach to their health and wellness – leading to a healthier population overall. 

The Benefits for Physicians

For physicians, the number one benefit of the value-based care system has to do with those aforementioned superior patient outcomes. 

Did some people become care providers to make as much money as possible? Certainly. They’re the ones who are likely not too happy with a shift of this magnitude. But for the doctors and other providers who got into this profession first and foremost because they wanted to help people, they’re now able to do so in a more lasting way than ever. Not only does patient health go up in the short term, but it also increases thanks to prioritizing things like preventative care, early intervention, and more. 

Finally, value-based care models make it easier (and more effective) for multiple providers to coordinate and collaborate with one another. If a patient is seeing three specialists, two aren’t impacted by the fact that one is insisting on tests and other procedures that are unnecessary or ineffective simply because of the financial incentive. Care providers can take an integrated, comprehensive approach to treating the patient. There will be fewer gaps in a person’s care plan, thus leading to better outcomes in a more effective way as well. 

Reporting Dashboards

There are tons of various reports offered on both the EMR and Billing modules. Advanced dashboards allow you to see your favorite reporting at a glance. We also offer the population health for tracking your MIPS QPP quality and improvement measures.  

ACOs: Meeting the Demand
for Value-Based Care

Playing an essential role in all of this are Accountable Care Organizations, otherwise known as ACOs for short. This is the name given to a group of not only doctors, but also hospitals, and other care providers who have all pledged to collaborate with one another, improving both the quality and the experience of care offered to patients. 

They use a variety of tech-based tools to help make this possible, with Electronic Health Record software being the prime example. For patients, the benefits of using an ACO come by way of the fact that you have multiple people all communicating and collaborating on care-based decisions, not just one. In most circumstances, this likely means that patients will go through fewer tests to arrive at a faster and more efficient diagnosis. This helps everyone involved save time on administrative tasks like paperwork, which allows for more time to devote to essential matters like the care itself. 

Indeed, ACOs also serve as an example of the important role that technology plays in things like value-based care. The concept of an EHR solution is certainly nothing new. Private practices, major healthcare systems, and virtually everyone in between have been using them in some capacity for years. 

What is notable is the fact that an EHR like PrognoCIS seems tailor-made to support initiatives like value-based care. Leading healthcare providers are finally understanding the importance of this shift, contextualized against the realization that many of the tools they need to make it happen are already there. They just need to be properly taken advantage of. 

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Medicare Advantage and the Future
of Value-Based Care

No discussion of value-based healthcare would be complete without mentioning  the Medicare Advantage Value-Based Insurance Design model. Recently extended through 2030, it is intended to allow the healthcare system in the United States to more thoroughly address the specific needs of patients, to advance health equity, and to improve care coordination, all at the same time. 

In 2024, there were 69 Medicare Advantage Organizations (also called MAOs) participating in this model, which covered more than 12 million people. At its core, the model is designed to remove some of the barriers that traditionally prevent people from seeking quality healthcare. These include things like: 

  • Not being able to financially afford to do so. 
  • Limited access to healthy foods based in income, geography, or both. 
  • Chronic health conditions that may have gone largely unmanaged up to this point. 
  • Transportation-related issues. 
  • And more. 

Through the Medicare Advantage Value-Based Insurance Design model, patients get access to custom benefits that are designed to address whichever issue they are facing. It’s not a “one size fits all” approach to care and is instead about providing a more personalized experience. 

If someone has let financial difficulty get in the way of managing chronic conditions, for example, they may be offered lower costs for prescription medications. If they don’t have a way to get to the doctor for preventative care, they might be able to take advantage of transportation services. Grocery assistance will be made available to help guarantee a patient can meet nutrition goals set by their care provider. 

From that perspective, the Medicare Advantage Value-Based Insurance Design model becomes both an example of value-based care in action, and an opportunity to take the principles inherent in a value-based approach and build on them moving forward. It’s all about furthering the mission that led to the creation of Medicare Advantage in the first place – offering a viable alternative to Original Medicare, which is the prime example of what “fee-for-service” healthcare is all about. 

Again, this model was recently extended through 2030 and every year it continues to evolve into a more patient-oriented program that helps increase choice, lower costs, and improve care quality across the board.

How Technology is Speeding the Shift to Value

Overall, technology has dramatically sped up the shift to value for organizations practicing value-based care. EHR solutions like PrognoCIS alone have made this digital transformation not only far easier to manage, but more successful over the long-term as well. 

Remember that an EHR platform like PrognoCIS is designed to act as a “single source of truth” for your practice. It brings together a lot of features that formerly required separate, disconnected solutions. As a result, data silos are eliminated, and you have full visibility over what you’re doing and who you’re helping, likely for the first time. 

Health management tools like the kinds included in these solutions help to proactively identify and track patients with specific health conditions. It highlights risk factors that may have otherwise gone unnoticed, leading to better outcomes in a more efficient way. 

EHR platforms naturally make it easier to securely communicate and collaborate with other providers, leading to higher-quality care coordination. Data analytics allow you to get a full view of someone’s entire health journey, giving you the chance to take meaningful steps for improvement wherever possible.

In the short-term, this type of tech-based revolution allows you to streamline your operations, reduce costs, and funnel that money back into your practice where it can improve the quality of care. Over the long-term, it helps make it easier (and more cost-effective) to embrace a value-based care model from the start.  As the quality of both patient care and the overall patient experience increases, so does patient engagement as well. Suddenly, a true competitive advantage presents itself for even the smallest practices. One satisfied patient turns into more through the power of word-of-mouth and your reputation alone, giving your practice a chance to scale in ways that may have been unthinkable even as recently as a decade ago.  All of it is possible thanks to the benefits inherent in the value-based care model, and the tech-driven solutions like EHR platforms that are making that vision a reality. 
Modern Medical Practice

Key Takeaways

Value-based healthcare involves a system where healthcare costs are dictated by the actual results being delivered to patients above all other factors.

With the current "volume over value" system, healthcare providers have a financial incentive to push some procedures and services over others simply because they can make more money doing so.

Value-based healthcare improves patient outcomes in the short-term, and also improves patient access to healthcare while tackling issues related to income inequality as well.

This is a topic very relevant to ACOs, or Accountable Care Organizations. These are groups of healthcare providers who all work together to improve the quality and experience of patient care.

One practical example of this is the Medicare Advantage Value-Based Insurance Design Model, which is intended to lower Medicare spending while improving the quality of patient care.

PrognoCIS and Value-Based Healthcare: The Perfect Pairing

At Bizmatics, we’ve designed PrognoCIS from the ground up to be the partner in digital transformation that your practice needs. We give you complete access to the tools needed to optimize workflows, reduce overhead, and increase revenue – all in one fell swoop. We want to prove that with the right technology by your side, adopting a value-based care model doesn’t have to mean taking a dramatic cut in your revenue. 

It just means making sure you have the right point-of-view when it comes to the patient experience – which in and of itself is the most important thing of all. The easier it is for you to provide the top tier care your patients want and deserve, the more money you make. It’s just that your practice isn’t generating revenue by prioritizing some more expensive services and procedures over others. 

It’s generating revenue by putting together the right care plan for the right patient at exactly the right time, which is precisely the way it should be. PrognoCIS offers revenue cycle management, practice management software, telemedicine solutions, and more – all so that nothing gets in between you and superior health outcomes. 

To find out more information about the ins and outs of value-based care, or to see what powerful EHR support software can do to help revolutionize and modernize your practice, please don’t delay - contact the team today. 

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