Value-based Care

Question 1

How do we define value?

Answer 1

• cost effectiveness
• biggest bang for the buck
• individual and community priorities
• value = outcomes/cost

Question 2

What are some value based care outcomes?

Answer 2

• emergency room utilization
• antidepressant continuation
• antidepressant initiation
• initiation of alcohol and other drug dependence treatment

Question 3

What are QALYs and DALYs?

Answer 3

Quality adjusted life years and disability adjusted life years

Question 4

What is fee for service?

Answer 4

Every visit, test, devise, and encounter was paid for separately

Also known as retrospective payment system

Question 5

What was the problem with fee-for-service?

Answer 5

Incentives overutilization of care

Question 6

What did Medicare Part A start using to control spiraling hospital costs?

Answer 6

Prospective payments

Question 7

What is a diagnosis related group?

Answer 7

Something that dictates reimbursement based on diagnoses, procedures, and case complexity

Question 8

Health care is moving away from paying for volume, and insurers are redesigning payments to incentivize ____ care

Answer 8

High quality, cost-effective

Question 9

What are the incentives for value based care?

Answer 9

Bonuses or penalties based on performance

Question 10

What are some quality measures?

Answer 10

• readmissions
• improvement over time
• cost savings
• possible focus on certain patient populations

Question 11

Are value-based payments supported by the data?

Answer 11

Not really

Question 12

Value-based payments are also referred to as ____

Answer 12

Alternative payment models (APMs)

Question 13

What are the three APMs?

Answer 13

• pay for performance
• bundled payments
• capitation

Question 14

What is pay-for-performance?

Answer 14

Providers are rewarded or penalized based on whether they meet pre-determined quality benchmarks

Question 15

What are bundled payments?

Answer 15

Providers receive a lump sum per episode and usually are rewarded through cost savings

Question 16

What is capitation? Who uses it?

Answer 16

Providers agree to coordinate care and meet quality benchmarks for a specified patient population, often per member per month fee

Medicare and Medicaid do this

Question 17

What is one-sided vs two-sided risk?

Answer 17

One sided: providers can only gain
Two-sided: providers may also lose

Question 18

What are Accountable Care Organizations (ACOs)?

Answer 18

• a payment model for primary care delivery
• groups of providers agree to treat a set population in exchange for PMPM payments
• value derived from cost savings, incentivizing preventative services and care coordination

Question 19

What are the effects of value based care on an organizational level?

Answer 19

• develop team based approaches between primary care and specialty care
• expanded options for patients
• increased importance of data and data analysis
• conflicting incentives of fee-for-service and value-based contracts
• mergers and alignment to gain a sense of “safety in numbers”

Question 20

What are the effects of value-based care on the provider level?

Answer 20

• increase productivity, not necessarily payment
• more task delegation
• more admin burden

Question 21

What are the issues with value-based care?

Answer 21

• inadequate care delivery due to different health record systems, inefficient points of access, and inability to make micro adjustments
• distorted incentives like kicking patients who miss an appointment because it costs them their evaluation
• errors in data integrity
• uncontrollable events that compromise prospective payment like new drugs

Question 22

What are social determinants of health?

Answer 22

Societal and environmental conditions

• food
• housing
• transportation
• education
• violence
• social support
• health behaviors
• employment