What are Value-Based Programs and How Do They Help You?

When you go to the doctor, the visit usually goes like this: you tell your doctor what is wrong, your doctor examines you, runs some medical tests, and may write prescriptions or send you elsewhere for more specialized treatment. Later, you and your insurance carrier are charged for the services provided. This is commonly referred to as fee-for-service reimbursement. Under this payment model, doctors are paid based on the number of people they see and the number of services they provide, but not on whether those services improved their patients’ conditions.

Arkansas Blue Cross and Blue Shield believes healthcare should focus on improved quality of care, a better experience for the patient, higher physician satisfaction and lower cost. For the past five years we’ve been involved in several state and federal programs focused on changing the payment model based on the triple aim. And, we are seeing positive changes in healthcare quality. Two models within these programs that have shown exciting progress are patient-centered medical homes and episodes of care.

In addition to the fee-for-service payment, primary care physicians in patient-centered medical homes are paid a set amount per member every month so they can focus more attention on each patient while seeing fewer patients a day. How can they do this? They have a support team to handle minor health issues and to reach out to patients. They also use technology to identify patients who need preventive care so they are less likely to get sick.

What is a patient-centered medical home (PCMH)?

In Arkansas, patient-centered medical homes have:

  • Lowered their overall costs
  • Improved workflows in the clinic to reduce patient wait times and add additional appointment times
  • Lowered admissions to hospitals
  • Educated patients with high-risk health conditions how to better manage their care
  • Addressed patients’ individual needs and concerns
  • Reduced wait times for patients through pre-visit planning
  • Developed pre-visit planning, which allows clinic staff to talk to patients about their needs before they come in
  • Created new ways to help patients get the care they need while working with several different doctors or understanding what they should do to avoid being admitted or re-admitted after they are released from the hospital

What are episodes of care?

Certain health conditions happen over a length of time. If you have a baby, that is usually nine months. For a knee replacement, it may be from the time you visited your doctor about pain in your knee, until you walked pain free. Episode-based payments to doctors focus on the quality of care delivered from all doctors and hospitals for that episode and create an incentive for a team approach in the best interest of the patient.

For instance, a knee replacement paid for as an episode of care would include all the patient’s care, from the first discussion about the surgery through rehabilitation. The doctor who takes the lead in caring for the patient (in this case, the surgeon) has a financial stake in making sure the patient gets the best care possible while keeping costs down.

Does it work? We have proven results! When reviewing the episodes of care for knee and hip replacements from 2013 through 2015, here is what we found:

  • Quality: The number of patients who ended up back in the hospital dropped 28 percent, and 44 fewer patients had to go back to the hospital because of infection.
  • Cost: There was a 2.5 percent decrease in the cost of the procedures
  • Use of Resources: The length of hospital stays was 9 percent shorter

What is your role?

Patient-centered medical homes and episodes of care are just two of the ways Arkansas Blue Cross is working with doctors and hospitals to reform healthcare. But there is someone else who needs to be involved in order for us to make the changes that will provide quality, affordable healthcare – you.

More than ever, it is vital for you to choose a primary care doctor you can trust, follow their care advice and build a relationship. As a patient, you have a responsibility to seek lower-cost medications when they are available and look at ways you can help cut medical costs.

We know medical costs are too high and we are working on innovative ways to lower those costs, both within our own company and in the medical community. Together, we believe we can provide smart, affordable healthcare to everyone.