By Rose O. Sherman, EdD, RN, FAAN
For decades in healthcare, nurse leaders have carefully watched the volume of care that was delivered in their departments because this has been the metric for reimbursement. We are now undergoing a transformational shift moving toward a system less focused on volume and more focused on value. It is happening slowly with changes in reimbursement but this is where we are headed in the future.
Hospital Value Based Purchasing was part of the affordable care act and the Centers for Medicare & Medicaid Services’ (CMS’) long-standing effort to link Medicare’s payment system to a value-based system to improve healthcare quality, including the quality of care provided in the inpatient hospital setting. Already, CMS has linked roughly 85% of traditional Medicare services to quality through accountability programs and penalties levied with 30 day readmissions. By 2018, this percentage will increase to 90%.
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.
What changes will 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. As an example, an emergency department director could see part of her /his role change to 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
CMS Value-Based Purchasing Program 2015
Deloitte Consulting Group. (2011) Deloitte Value Based Purchasing
© emergingrnleader.com 2015
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