Katie the Intern 12/18/20

This week’s focus was on how healthcare has begun to change from a fee-for-service model to a value-based model for some providers. I interviewed Matt Lambert, MD, who has served as chief medical officer at Curation Health for the past two years. Dr. Lambert is a practicing provider who has also authored multiple books about healthcare. 

Curation Health is a technology and services company that helps healthcare providers and organizations transition from fee-for-service to value-based care, Dr. Lambert said. Curation Health uses tools to sort data so that providers can capture certain diagnoses for their patients. 

“Physicians never signed up to be data managers,” Dr. Lambert said. “So anything that we can do to help manage data and the regulation for them is usually pretty well received by providers.” 

I know that 99% of HIStalk readers probably know the difference between the two models of healthcare application, but as someone new to the IT field, I asked Dr. Lambert just how different they are. Value-based care reimburses on outcomes, while fee-for-service reimburses on volume, he said.

“The currency of value-based care is some very specific diagnoses that need to be made and need to be managed on a yearly basis in order for you to get compensation for managing the complexity of your patients,” Dr. Lambert said. 

As we talked about what Curation Health does, we also focused on how the pandemic impacted the trend of shifting to value-based care.

“This shift was happening already,” Dr. Lambert said. “The payers are always more nimble than the providers. Providers are lagging in the transition into this.” Health systems and providers are built on a system that requires month-to-month, short-term investments, but value-based care gets reimbursed yearly.

“Just by definition, you have to have the ability to look a year down the road and say, hey, we’re going to make some changes to our business model now, it’s going to pay off in a year,” Dr. Lambert said. “But most health systems aren’t created that way. They’re built off of fee-for-service models.”

Establishing reimbursement for care isn’t the only struggle that providers face when adjusting to value-based care. Dr. Lambert said providers also have to learn how to document their care differently, as well as work against the typical workflow of an EHR. The typical workflow is designed to have an output of an E&M code (evaluation and management, got it), which is a fee-for-service model component.

“One of the reasons why providers are struggling in the shift to value-based care is because we’re asking them to do something they weren’t trained to do with a tool that is not designed to do it,” Dr. Lambert said. 

The shift towards value-based care was implemented in 2008, and providers are still struggling to make the switch. I wondered how COVID-19 affected it.

Dr. Lambert said that COVID-19 slowed down the ability for providers to physically see patients in a face-to-face manner because in order to get credit for managing a patient, providers have to physically see them. That is, providers used to have to do so. 

Dr. Lambert mentioned that the initial shift to value-based care was driven by CMS (Centers for Medicare and Medicaid Services, noted). When the pandemic hit, CMS was quick to deregulate the rules for reimbursement through value-based care.

“Telehealth became eligible for a risk-adjustment visit for value-based care visit,” Dr. Lambert said. Here, telehealth strictly means a video visit, as “telephonic” visits do not qualify as value-based care as of now. Dr. Lambert said CMS removed the HIPAA compliance requirements for a lot of visits, allowing more access to patients and a wider medium for providers. 

Though moving to value-based care is not the easiest task, adjusting to this new system of care is important for providers. According to Dr. Lambert, it isn’t just a care-based adjustment, but also a business one. 

“This is how the payers are going to reimburse you, and moving forward, if you continue to do things the same way, you’re going to fall behind in the way you get reimbursed,” Dr. Lambert said. 

Dr. Lambert also said value-based care is set up to compensate for and incentivize different things. It is set up to incentivize information sharing and care coordination, which encourages patients to be engaged with doctors and their health. It does so in a way that encourages outcomes, not just in the idea that a patient has to come back the following week or month, he said. 

Overall, Dr. Lambert says value-based care will to continue to grow through commercial and public incentives. He said there will be a lag into 2021 due to all the closures and limited care from the pandemic. But afterwards, there will be an increase in utilization and in compensation. He isn’t sure exactly where value-based care is going, but did say telemedicine improved dramatically through COVID-19 and will continue to do so. Perhaps that intersection of telemedicine and value-based care will be a sweet spot in providing better care and compensation for all. 

“It’s not very often in our lives that we try something new until circumstances force us to do that,” Dr. Lambert said.

That’s it for this week! Thanks, HIStalk! 

Katie The Intern

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