Putting the Value in Value-Based Contracting

The healthcare industry is in the midst of a significant shift that affects both the way healthcare services are paid for and the way they are delivered. Payers are rapidly moving away from a mostly fee-for-service reimbursement model, to one that is increasingly structured around value-based contracting in many different forms, from bundled pricing that includes post-procedure care, to PCMH, to ACO’s and many variants of each. Even the CMS penalties for hospitals with high readmission rates are a form of value-based contracting.

The rise of Value-Based Contracting

In the old fee-for-service model, the doctor organizes their time to treat the patient sitting in front of them, and they get paid to treat the patient who shows up for whatever reason. But now, with the shift to an outcome-based model, doctors must ask themselves, “Which of my patients who is not sitting in front of me, should be? I have finite resources, what is the best use of my next hour?”

Once a doctor internalizes the question, “Who should I see today to make the greatest impact?” the next step is to figure out how to do that.

The most common answer over the past few years has been risk stratification based on claims, diagnosis, or BMI combined with age and risk-factors, which narrows the patient pool considerably. Instead of several thousand patients per doctor, the list has been narrowed to several hundred.

Risk stratification is helpful, but it doesn’t identify which patients a doctor should see today.

Patient Data: Objective Measurements

The rise of connected devices allows the health care system access to data about a patient who is outside the traditional boundaries of the health care system. For a number of years, hospitals have outfitted their sickest cardiac patients with BP cuffs that the patients could use at home, and in the past few years there has been an explosion of sensors that a patient can use to monitor a variety of vital signs.

For some conditions, like diabetes, a single measure (HA1C) can provide important insights on the patient although in practice this is more often useful for retrospective review. But for most of the patients who need to be monitored, a more comprehensive understanding of the patient is required in order to determine which patient may be in need of intervention today.

We believe that the future of tele-monitoring will be a combination of sensor based data combined with patient-reported data about their day-to-day experience. This patient reported data will include pain levels, emotional and physical status, specific symptoms that are relevant for the patient’s condition, and finally medication compliance information.

The Critical Role of Patient Reported Information

Only the patient can tell if they are in pain, or experiencing a particular symptom or side effect. And the symptoms the patient notices are important because they may very well be impacting their quality of life or keeping them from following medication instructions. Not to mention that when these symptoms are reported alongside objective measurements like blood pressure, number of steps, etc. the objective measures are more useful.

With the limited time the patient and doctor have together in the exam room, and the inherent difficulty patients have remembering how they felt a week or a month ago, let alone how often they experience a symptom and when it first began, patients are often ill equipped to tell their doctors what they really need to know. We’re working to change that. Value-based contracting can’t rely on traditional measurements, like claims data, alone. It requires ways to effectively monitor, manage and measure patient progress day-to-day.

In the future, I believe it will be common for an at-risk patient to receive a call from a nurse care manager to discuss a specific problem or to ask them to come in for an unscheduled appointment based on what they reported using TapCloud.

Actually for the patients and doctors we work with, that already happens every day.