From Volume to Value-Based Care - Emerging Nurse Leader

By Rose O. Sherman, EdD, RN, FAAN

This past weekend, Dr. Tim Porter O’Grady (a nurse futurist) spent time with our emerging nurse leader students and their preceptors discussing the changing role of the nurse leader in the new evolving health-care delivery system. One significant change in health reform is the movement of reimbursement away from a focus on the volume of services to a focus on the value of services delivered during an episode of care. This is what Tim describes as one of the rivers of change in health reform. It is a radical shift that will require of all of us in health-care to embrace new ideas and release old ones.

I reflected on Tim’s thoughts as I spent time with an emergency department director yesterday. We talked about health reform and what it might mean to her specialty. She remarked, “Our whole model in the emergency department is based on the volume of our services. I can think of no other specialty area that could be impacted more by health reform. Currently about 40% of our patients are not true emergencies. With a focus on prevention and more patients insured, our volumes are sure to drop. In fact, the goal will be to keep patients out of EDs where the cost of care is quite high. This will be a huge culture change for us.”

What is Value-Based care?

Value-based care is a payment methodology that shifts the focus from the number and type of services delivered to one that rewards quality, safety, efficiency and lower costs. A frequent complaint about health-care today is the lack of transparency in costs. A value-based purchasing model will usually involve bundled payments for an episode of care usually 30, 60 or 90 days. Under this bundled payment, hospitals and other providers assume the financial risk for delivering all care for one price. In a value-based model, providers are accountable for the quality and costs of health services. There are usually predetermined performance measures. The system is designed to eliminate costly, inappropriate or unnecessary care such as frequent trips to emergency departments.

To effectively determine costs and outcomes and price these services, providers and hospitals need data. The electronic record meaningful use requirements in the high tech act described in a previous blog is legislation designed to help organizations and providers have the data they need to make decisions about costs. There are many pilot projects that are underway throughout the country testing the bundled payment process. The cover story in this week’s Hospitals and Health Networks frames the issue and illustrates some of the opportunities and challenges.

What changes could it bring to the nurse leader role?

A value-based purchasing model changes the focus of care from quantity of services delivered to streamlining care to achieve the best outcomes. Nurse leaders will need to adopt a very strategic mindset as they work on interdisciplinary teams that formulate plans to manage patient episodes of care. In the case of my emergency department colleague, part of her new role may involve analyzing the risk of ED use of certain groups of patients. The goal will be to reduce ED care. Most experts are also predicting that shortened lengths of stay and reduced hospitalizations may inevitably lead to bed/hospital closures.

Nurse leaders have a unique opportunity at this time to lead and contribute to the redesign of health care delivery models that focus on wellness and prevention, rather than simply on the acute care management of patients. The traditional nursing care delivery models that we have used focus on the episodic management of patients while they are in the hospital. This will need to change. Nursing will assume more accountability to manage patients across the continuum of care as part of the change in reimbursement. It is a challenging but also exciting time as we move forward into what will be a very different health care system than the one currently in place.

Read to Lead

Deloitte Consulting Group. (2011) Deloitte Value Based Purchasing