Value-Based Care: An Executive Briefing

Abstract

In today’s challenging health care environment, the paradigm shift from volume to value requires nurse leaders to develop enhanced skills to transform health care in 2020. Key drivers for success include: igniting innovation and change; embracing data and analytics; and launching new care delivery models that soar beyond organizational boundaries. Value-based care is here to stay, and nursing must be the catalyst for change. Equipped with new skills and the knowledge of CMS Pay for Performance programs, nurse leaders will design the future health care landscape. In today’s challenging health care environment, the paradigm shift from volume to value requires nurse leaders to develop enhanced skills to transform health care in 2020. Key drivers for success include: igniting innovation and change; embracing data and analytics; and launching new care delivery models that soar beyond organizational boundaries. Value-based care is here to stay, and nursing must be the catalyst for change. Equipped with new skills and the knowledge of CMS Pay for Performance programs, nurse leaders will design the future health care landscape. Key Points•As the value movement pushes forward; nursing has the unique opportunity to align with the tenets of healthcare reform and to lead this clinical transformation.•Nurses, from leadership to the frontline staff, must embrace innovations in care that support the Triple Aim, and must cultivate a vision that spans interdepartmental boundaries, extending beyond the bricks and mortar of acute care.•The journey to value has been set; nursing must take a seat at the design table as the blueprint for the future of healthcare is drawn. •As the value movement pushes forward; nursing has the unique opportunity to align with the tenets of healthcare reform and to lead this clinical transformation.•Nurses, from leadership to the frontline staff, must embrace innovations in care that support the Triple Aim, and must cultivate a vision that spans interdepartmental boundaries, extending beyond the bricks and mortar of acute care.•The journey to value has been set; nursing must take a seat at the design table as the blueprint for the future of healthcare is drawn. As part of the spotlight on value-based care (VBC) and as mandated by the Affordable Care Act (ACA) of 2010, the Centers for Medicare & Medicaid Services (CMS) introduced 3 programs that reimburse acute care hospitals based on value. These 3 pay for performance programs or value-based care programs include Hospital Value-Based Purchasing (HVBP), Hospital Readmissions Reduction Program (HRRP), and Hospital-Acquired Conditions Reduction Program (HACRP).1Brooks J.A. Reducing hospital readmissions.Am J Nurs. 2015; 115: 62-65Crossref PubMed Scopus (1) Google Scholar,2Brooks J.A. The hospital-acquired condition reduction program.Am J Nurs. 2017; 117: 63-66Crossref PubMed Scopus (1) Google Scholar These programs focus on the value or the quality of services rendered rather than the volume of services provided. Value-based care was developed in response to the unsustainable escalation in health care costs, poor quality outcomes, and shifting demographics. VBC is the underlying strategy in Healthcare Reform, also known as the Affordable Care Act (ACA) of 2010.3Salmond S. Echevarria M. Healthcare transformation and changing roles for nursing.Orthop Nurs. 2017; 36: 12-25Crossref PubMed Scopus (107) Google Scholar The ACA was designed to create a framework that embraces the Institute for Healthcare Improvement’s (IHI) Triple Aim of enhanced patient experience and outcomes, improved population health, and reduced health care expenditures.4Institute for Healthcare ImprovementIHI triple aim initiative.http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspxDate: 2015Date accessed: February 26, 2020Google Scholar This fundamental reform legislation created a paradigm shift from a volume focus, where providers were rewarded for the number of tests or procedures performed to a value-based structure that incentivizes providers to deliver quality at a reduced cost.5Aroh D. Colella J. Douglas C. Eddings A. An example of translating value-based purchasing into value-based care.J Urol Nurs. 2015; 35: 61-74Crossref Google Scholar This paradigm shift from volume to value is a call to action for nursing. Salmond and Echevarria3Salmond S. Echevarria M. Healthcare transformation and changing roles for nursing.Orthop Nurs. 2017; 36: 12-25Crossref PubMed Scopus (107) Google Scholar highlight the importance of nursing as a critical player in this health care transformation. Nurses are prepared to move into roles to improve health and influence clinical outcomes. The Institute of Medicine6The Institute of MedicineThe Future of Nursing: Leading Change, Advancing Health. Academies Press, Washington, DC2010Google Scholar report on The Future of Nursing also emphasizes the significant impact and contribution of nursing in this paradigm shift, known as health care reform. Nurses at all levels must understand the vital transformation required for success in health care reform and must be committed to delivering safe, cost-effective care. This active engagement of nurses and nurse leaders is crucial to the success of health care reform, not only to affect reimbursement dollars but to transform care and affect patient care outcomes across the continuum.7Brooks J.A. Understanding hospital value-based purchasing.Am J Nurs. 2016; 116: 63-66Crossref PubMed Scopus (2) Google Scholar As leaders plan for this transformation, implementation of new care delivery models that focus on care coordination beyond the 4 walls of an acute care setting will drive success. This novel approach will present a challenge for most organizations and will require a new skill set for nurse leaders.8Jacquin L. A strategic approach to healthcare transformation.HFM. 2014; 68: 74-79Google Scholar This new skill set will include understanding the principles of population health, developing financial acumen, and acquiring data analytic skills.9Randazzo G. Challenges and opportunities facing nurse executives in the era of value-based care.Nurse Leader. 2018; 16: 96-100Abstract Full Text Full Text PDF Scopus (2) Google Scholar The purpose of this manuscript is to present a summary of the VBC programs for acute care hospitals, highlighting key points that are vital to the nurse leader's success as a transformational leader. This article describes the current VBC landscape with a glimpse into the future changes in the reimbursement models. Specific implications for nursing will also be explored to equip the nurse leader with the skills to thrive in this new era of value-based care. In response to the ACA, the CMS introduced 3 pay for performance or VBC programs that reimburse acute care hospitals based on value, not volume. These value-based care programs include HVBP, HRRP, and HACRP.1Brooks J.A. Reducing hospital readmissions.Am J Nurs. 2015; 115: 62-65Crossref PubMed Scopus (1) Google Scholar Value, as defined by the CMS, is a ratio of quality and outcomes divided by cost.3Salmond S. Echevarria M. Healthcare transformation and changing roles for nursing.Orthop Nurs. 2017; 36: 12-25Crossref PubMed Scopus (107) Google Scholar This value is measured differently in each CMS program. HVBP was created to link the Medicare payment system to inpatient quality through an incentive payment based on a total performance score (TPS). That TPS is calculated based on performance in the 4 domains of clinical care, safety, efficiency, and patient experience. Throughout the history of the program, the measures and the weighting of each domain has changed, as the movement from a process focus to an outcome and efficiency approach has evolved.7Brooks J.A. Understanding hospital value-based purchasing.Am J Nurs. 2016; 116: 63-66Crossref PubMed Scopus (2) Google Scholar The HRRP imposes a maximum penalty of 3% for 30 days all-cause readmissions in several cohorts, including acute myocardial infarction, chronic obstructive pulmonary disease, pneumonia, total joints, and coronary artery bypass graft surgery. The CMS compares an actual readmission rate to an expected rate for 3 years. These values are then risk-adjusted to provide a more fair comparison among facilities.1Brooks J.A. Reducing hospital readmissions.Am J Nurs. 2015; 115: 62-65Crossref PubMed Scopus (1) Google Scholar The HACRP imposes a 1% reduction in Medicare reimbursement to those facilities in the worst-performing quartile. This program focuses on 5 hospital-acquired infections (HAI): catheter-associated urinary tract infections (CAUTI), central-line–associated bloodstream infections (CLABSI), surgical site infections (SSI), Clostridium difficile infections (CDI), and methicillin-resistant Staphylococcus aureus (MRSA) in 1 domain of HACRP. In the second domain of HACRP, a composite score for the Agency for Healthcare Research and Quality (AHRQ) patient safety indicators, known as PSI-90, is assessed.2Brooks J.A. The hospital-acquired condition reduction program.Am J Nurs. 2017; 117: 63-66Crossref PubMed Scopus (1) Google Scholar As the drive to value has continued to evolve, clinical integration across the care continuum is paramount for success in these programs. Nursing has a unique opportunity to align with the tenets of health care reform and lead this health care transformation.5Aroh D. Colella J. Douglas C. Eddings A. An example of translating value-based purchasing into value-based care.J Urol Nurs. 2015; 35: 61-74Crossref Google Scholar To ignite these changes, nurses from leadership to frontline staff must embrace innovations to deliver care that supports the Triple Aim.3Salmond S. Echevarria M. Healthcare transformation and changing roles for nursing.Orthop Nurs. 2017; 36: 12-25Crossref PubMed Scopus (107) Google Scholar Nursing is a critical player that can directly or indirectly influence hospital performance in the 3 CMS value-based care programs. In HVBP, the patent experience domain score is driven by results from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). HCAHPS is a patient experience survey that includes questions about topics such as discharge planning, communication, and responsiveness of the staff. The most significant impact on these HCAHPS scores is nursing care.10Wolosin R. Ayala L. Fulton B. Nursing care, inpatient satisfaction, and value-based purchasing: vital connections.J Nurs Adm. 2012; 42: 321-325Crossref PubMed Scopus (41) Google Scholar Another HVBP domain, safety, includes an assessment of hospital-acquired infections impacted by evidence-based care nursing interventions or basic hand-washing.7Brooks J.A. Understanding hospital value-based purchasing.Am J Nurs. 2016; 116: 63-66Crossref PubMed Scopus (2) Google Scholar The same nursing interventions that can reduce or eliminate hospital-acquired infections for HVBP affect the HACRP as well. The HACRP focuses on reducing the same 5 hospital-acquired infections: CLABSI, CAUTI, MRSA, CDI, and SSIs. CMS has stressed the importance of preventing HAIs by including them in 2 separate programs, HVBP and HACRP, and penalizing hospitals twice for insufficient scores in these areas. Nursing’s role in readmission reduction or HRRP extends beyond acute care and must include a pre-discharge and post-discharge focus.1Brooks J.A. Reducing hospital readmissions.Am J Nurs. 2015; 115: 62-65Crossref PubMed Scopus (1) Google Scholar Nurses are at the heart of coordinated, evidence-based care, and they must seize the opportunity, not only to manage the patient in the acute care arena, but also to transcend boundaries across the continuum. Nursing has a pivotal role in the success of health care reform, as nurses impact clinical quality outcomes in many locations across the care continuum.6The Institute of MedicineThe Future of Nursing: Leading Change, Advancing Health. Academies Press, Washington, DC2010Google Scholar This enhanced focus beyond acute care will require a new set of skills, as the shift from episodic care to patient-centric care guides the value-based care transformation forward.3Salmond S. Echevarria M. Healthcare transformation and changing roles for nursing.Orthop Nurs. 2017; 36: 12-25Crossref PubMed Scopus (107) Google Scholar Ensuring safe transitions of care and forging new collaborative professional partnerships are an essential skill in the latest value-based care framework.11Salmond S.W. Forrester D.A. Nurses leading change: the time is now.in: Forrester D.A. Nursing's Greatest Leaders: A History of Activism. Springer Publishing Company, New York, NY2016: 270-284Crossref Google Scholar Nurses are well poised to bridge the gap in fragmented services and to reduce adverse patient outcomes through care coordination. Key strategies to facilitate this enhanced coordination of care include a focus on patient and family engagement, self-management skills, interdisciplinary collaboration, and effective communication.3Salmond S. Echevarria M. Healthcare transformation and changing roles for nursing.Orthop Nurs. 2017; 36: 12-25Crossref PubMed Scopus (107) Google Scholar These nursing interventions are the first step on the journey to reduce readmissions, improve patient outcomes, and reduce cost. Managing care across the continuum also demands a novel approach to the care delivery model that aligns patient priorities with provider services. This alignment supports a VBC strategy that serves as a foundation for optimizing patient results. As organizations move to this integrated, team-based delivery model, nurses, as the coordinators of care, will lead this transformation.8Jacquin L. A strategic approach to healthcare transformation.HFM. 2014; 68: 74-79Google Scholar Nurses are the crucial hub that links individuals with the disparate spokes of the health system. They have the clinical knowledge, leadership, and skill set to assume critical roles in care coordination.3Salmond S. Echevarria M. Healthcare transformation and changing roles for nursing.Orthop Nurs. 2017; 36: 12-25Crossref PubMed Scopus (107) Google Scholar This care coordination supports the drive to value; however, a much broader nursing focus is an essential part of the blueprint for VBC success. Salmond and Echevarria3Salmond S. Echevarria M. Healthcare transformation and changing roles for nursing.Orthop Nurs. 2017; 36: 12-25Crossref PubMed Scopus (107) Google Scholar highlight a framework that concentrates on patient's needs and impacts outcomes, not only across the care continuum, but also through the trajectory of life. Addressing chronic care issues across the entire population will support the drive to safe, cost-effective care. Individuals with 3 or more chronic conditions, known as polychronic, however, present a new challenge for health care reform. Projections show that this polychronic population will grow drastically over the next 15 years.12Waters H. Graf M. The Cost of Chronic Disease in the U.S. Milken Institute, Santa Monica, CA2018Google Scholar Mihailoff et al.13Mihailoff M. Shreyasi D. Lee J. Lynn J. The effects of multiple chronic conditions on adult patient readmissions and hospital finances: a management case study.Inquiry. 2017; 5446958017729597PubMed Google Scholar demonstrated the severe financial impact that this population has on the health care system with increased lengths of stays and high readmission rates. Innovations in nursing are needed to navigate uncharted waters and to rise to meet these population management challenges. One such innovation is the concept of a flipped discharge, where critical elements of the discharge process are moved beyond the 4 walls of the hospital to the home environment. The first step in this process is a geriatric inpatient assessment to identify patients that may benefit from this approach. An individualized plan is created that focuses on a holistic, comprehensive approach with intensive, timely services. Other tenets of a flipped discharge include thorough handoff communications and in-home assessments of functional capacity. Penn Medicine has seen promising results in reduced readmissions and increased patient satisfaction.14Cheney C. Flip Your Discharge Model to Decrease Length of Stay. 2018. Health Leaders website.https://www.healthleadersmedia.com/welcome-ad?toURL=/clinical-care/flip-your-discharge-model-decrease-length-stayGoogle Scholar In addition to the flipped discharge model, technology enhancements help to complement chronic care management by extending the provider’s reach into the home. Wearable devices, such as heart rate monitors or glucose monitors, can transmit data to patient portals or other sites. Other innovative tactics include remote patient monitoring that drives positive lifestyle changes.15Fields R. New strategies for condition management within value-based care.Generations. 2019; Suppl: 24-27Google Scholar The Hypertension Digital Medicine Program offered at Oschner Health Systems in New Orleans is one such program that establishes this remote connection. Patients are given a digital device that can transmit blood pressure readings directly into the electronic health record. Collaboration among the health care team members leads to an individualized treatment plan based on this clinical data and insight gained from lifestyle risk surveys.16Tai-Seale M. Downing N.L. Jones V.G. Milani R.V. Technology-enabled consumer engagement: Promising practices at four healthcare delivery organizations.Health Aff (Millwood). 2019; 38: 383A-390ACrossref PubMed Scopus (19) Google Scholar This collaboration is a hallmark of nursing and a pillar of success for the transition to value. Key focal areas in this transition to value include a population management strategy that embraces the legacy of nursing practice, which is the coordination, advocacy, and collaboration.17Storfjell J.L. Winslow B.W. Saunders J.S.D. Catalysts for Change: Harnessing the Power of Nurses to Build Population Health in the 21st Century. The Robert Wood Johnson Foundation, Princeton, NJ2017Google Scholar This population management strategy must be supported by care delivery models that span the care continuum and incorporate team-based care as the norm. As polychronic patients increase in number and complexity, further draining health care resources, innovative approaches, and technology enhancements will provide the tools for nursing to revolutionize health care. In addition to a population management strategy that drives positive patient outcomes, nursing leaders must look to the future, with a new vision that incorporates an expanded knowledge of the value conundrum. Equipped with skills to thrive in this new, exciting era, nurse leaders will chart the course to transform health care. These essential leadership skills include embracing technology and big data, igniting change and innovation, soaring beyond organizational boundaries, and launching new care delivery models.9Randazzo G. Challenges and opportunities facing nurse executives in the era of value-based care.Nurse Leader. 2018; 16: 96-100Abstract Full Text Full Text PDF Scopus (2) Google Scholar,18Larson L. The rapidly evolving role of nurse execs.H&HN. 2017; 91: 28-31Google Scholar Nurse leaders must rise to the challenges of the big data revolution, as the futurists who help design meaningful information from a great deal of data. Big data, the foundation of population management, provides insight into needed strategies to accomplish the Triple Aim. Nurse leaders must be able to extract key findings from data analyses and convert them into operational tactics aimed at safe, cost-effective care. These data competencies are a vital link to success in a value-based care world.19Englebright J. Caspers B. The role of the chief nurse executive in the big data revolution.Nurse Leader. 2016; 14: 280-284Abstract Full Text Full Text PDF Scopus (4) Google Scholar In addition, nurse leaders must develop a culture of innovation, where piloting fresh ideas is encouraged. The status quo can no longer be accepted. Cultivating a vision that spans internal departmental boundaries, and extends beyond bricks and mortar of acute care is vital. Value-based care crosses the care continuum, and nursing care must also span these horizons.18Larson L. The rapidly evolving role of nurse execs.H&HN. 2017; 91: 28-31Google Scholar Partnering with post-acute care providers to establish preferred networks is only an initial step in the process. Nurse leaders must sit side by side with key stakeholders and develop a collaborative approach to manage complex cases, across multiple settings. Effective outcomes and cost savings will not be realized if clinical strategies do not encompass a 360° view. As the value movement pushes forward, the future direction is clear. The journey to value has been set; only the specific directions have become obscure with disparate political agendas and mixed reviews on the effectiveness of the various CMS programs. These VBC programs are evaluated annually by the Medicare Payment Advisory Commission (MedPAC) and summarized in a report to Congress. Quality of care and Medicare payments are 2 significant components in the annual MedPAC review. Recent reports have shown that mortality and readmission rates have improved slowly, whereas improvement in HCAHPS patient experience scores has inched along. Medicare spending continues to increase but at a more sustained rate than in prior timeframes.20Medicare Payment Advisory CommissionReport to the Congress: Medicare Payment Policy. Medicare Payment Advisory Commission, Washington, DC2019Google Scholar Although MedPAC has realized the success of the VBC programs, there is growing concern that the design methodology of these programs is too complicated, too repetitive, and a burden on providers. To correct these design flaws, the Commission has proposed an impressive solution, known as the Hospital Value Incentive Program (HVIP). HVIP will replace the current, fragmented CMS programs with one seamless payment program for acute care hospitals. It will include the elimination of the current Inpatient Quality Reporting Program (IQRP) and the merging of the 3 traditional CMS VBC programs, HRRP, HVBP, and HACRP, into 1 payment model. This new model will include 5 domains that are composed of 1 all-condition readmission measure, 1 all-condition mortality measure, a hospital-acquired infections composite, the Medicare Spend per Beneficiary ratio, and a patient perception composite. The recommendation to implement HVIP was sent to Congress in March 2019 and is awaiting further legislative action.20Medicare Payment Advisory CommissionReport to the Congress: Medicare Payment Policy. Medicare Payment Advisory Commission, Washington, DC2019Google Scholar In addition to the recognition that the CMS P4P programs need to be streamlined, CMS has also realized the disparities between social groups and the impact on clinical outcomes. The 21st Century Cures Act of 2016 mandated that CMS change the methodology in the HRRP FY2019 program to reflect differences in sociodemographic profiles, based on dual eligibility. Dual eligibility refers to patients that have Medicare fee-for-service coverage but also qualify for Medicaid. Hospitals are grouped into 5 peer groups based on this dual-eligible proportion and are evaluated for the readmission penalty, with other facilities that have a similar sociodemographic footprint.21Centers for Medicare & Medicaid ServicesNew Stratified Methodology Hospital-Level Impact File User Guide. Centers for Medicare & Medicaid Services, Baltimore, MD2017Google Scholar This change has improved the HRRP methodology with a decrease in penalties for facilities that have high-risk populations. Dual eligibility also laid the foundation for further analyses and insight into the vital impact that social risk factors have on a patient’s health status. Social determinants of health (SDoH) date back to 2005 when the World Health Organization created a Commission on SDoH, but it was not until recently that the concept of SDoH has been embraced by professional organizations.22World Health OrganizationSocial Determinants of Health.https://www.who.int/social_determinants/strategic-meeting/en/Date: 2019Date accessed: March 3, 2020Google Scholar SDoH includes social conditions such as housing, food, transportation, employment, and education. SDoH are now included as Z-codes in the ICD 10 coding classification, offer a robust method to capture this crucial data in the patient's record, and guide clinical care. Despite the availability of these codes, however, very few hospitals have adopted their use.23American Hospital AssociationICD-10-CM Coding for Social Determinants of Health.https://www.aha.org/system/files/2018-04/value-initiative-icd-10-code-social-determinants-of-health.pdfDate: 2019Date accessed: March 1, 2020Google Scholar Nurses are educated to assess patients holistically, in the context of this SDoH framework, and are the likely profession to adopt this agenda. Nursing leadership has the opportunity to realize the significance of these valuable data and push for their implementation throughout the organization. Value-based care is here to stay, because payment for volume is no longer sustainable.24Remarks by Administrator Seema Verna at America's Health Insurance Plan's (AHIP) 2019 National Conference on Medicare [press release]. Centers for Medicare & Medicaid Services, Baltimore, MD2019Google Scholar Our national health care system is in a state of flux, demanding quality at a reduced cost. The time is now for nursing to move front and center to lead this transformation. The Institute of Medicine6The Institute of MedicineThe Future of Nursing: Leading Change, Advancing Health. Academies Press, Washington, DC2010Google Scholar report is complete with evidence of nursing’s influence on safe, patient-centered, cost-effective care. Nursing is pivotal to the success of value-based care. This paradigm shift demands that nursing develops enhanced skills and demonstrates courage, wisdom, and passion for navigating unchartered waters. Nursing must demand full partnership and take a seat at the design table as the blueprint for the future of health care is drawn.