In his role as Chief Medical Officer of PointClickCare, Dr. Ben Zaniello has insight into the impact of value-based care, from the challenges of frontline care workers to the payment models that drive healthcare as a business.
In this Value-Based Care Series interview, Zaniello discusses the challenges and opportunities value-based care has created at every level of PointClickCare’s partner organizations, providing a unique perspective on the role technology has played in shaping the transition thus far. Zaniello describes the importance of patient insights in achieving improved patient outcomes despite staffing challenges, and he also explains what steps SNFs can take to amplify their voices in the VBC conversation.
In one sentence, define what value-based care means to you.
Value-based care alludes to a different reimbursement model where reimbursement in health care is no longer based on what you do to or for a patient. Instead, it is based on what clinical outcomes are achieved by your care. Ok, that’s two sentences!
What does value-based care require in order to be successful?
It requires many things, unfortunately [laughs]. It requires a relationship with the patient. It requires insights into the patient. It requires alignment across the care teams working with the patient. Then ultimately, it relies on everyone working in the most cost-effective manner with each person performing their designated duties, at the top of their license, across the care continuum.
What are the biggest hurdles to achieving value-based care in today’s health care landscape?
Today, only a small percentage of the healthcare market is value-based care-oriented, and it is still primarily focused on fee-for-service revenue and reimbursement. That is particularly true in the post-acute space.
There are not many value-based quality measures in place, and they’re limited in their scope and impact. For example, the Medicare five-star ratings focus on proxy, process-oriented measures like staffing ratios instead directly on outcomes of care.
That is significant because it means that if you come up with a way to achieve better clinical outcomes with fewer staff — perhaps possible with remote patient monitoring — the current value-based care construct in the post-acute world would actually penalize you!
Do you see any downsides to value-based care?
Following up on my previous point, it’s hard to come up with appropriate, obtainable measures for patient outcomes and clinical outcomes across the care continuum. Today we use a lot of proxies for success, with mixed results. A classic example from the primary care space is hemoglobin A1C, which is a measure of blood sugar over a period of time. This a quality metric used to measure someone’s diabetes control and ideally reflects your and the patient’s ability to control their diabetes.
Unfortunately, diabetes control is more than the medications you prescribe to a patient, how often you test that A1C, and how many appointments they go to. There are many other factors like their adherence to those medications, their daily diet and exercise. These are things providers cannot control, yet they determine the ultimate clinical outcome of your interventions, and therefore, in value-based care, your reimbursement.
The classic post-acute examples are readmissions and rehospitalizations. You can have the best possible discharge for a patient out of your post-acute facility, but due to factors beyond your control (did they take their medications?), they may need to either return to your facility or return to the emergency department and hospital. Focusing reimbursements on events out of provider control does not feel especially fair.
How do you think PointClickCare, specifically, has supported the shift to value-based care?
The most important thing to support our providers is to give them targeted patient insights, focusing their efforts on the highest risk patients, and then guide them to the most appropriate interventions possible to provide the best possible care. It starts with meaningful data, highlighting things in the medical record that says, “these are potential red flags for this patient that may benefit from early intervention.” Then we provide evidence-based clinical pathways, like Nursing Advantage, to guide providers to the best possible outcome for that patient.
That said, value-based care is ultimately bigger than one skilled nursing facility, one hospital, any one part of the care continuum. It’s looking across the entire patient journey, with multiple locations, providers, and opportunities to make care better (or worse!).
So it’s important that these disparate caregivers can share timely information about shared patients, because an insight from one part of the care continuum could optimize the intervention in another part.
To that end, PointClickCare has invested heavily into cross-facility care collaboration with our acquisitions of Collective Medical and Audacious Inquiry. Their tools create the most complete possible view of a patient, so providers can gain visibility into that patient’s clinical context at the point of care. They also help optimize patient discharges by providing visibility into a patient’s outpatient care. Because again, every part of the care continuum factors into a patient’s outcomes, so maximizing care collaboration across facilities allows providers to maximize clinical outcomes and ultimately, their reimbursement.
Why do you think it’s been so hard for skilled nursing facilities to get a seat at the table when it comes to value-based care?
First and foremost, health plans and ACOs have been slow to recognize the impact that post-acute and skilled nursing facilities can have on a patient’s care. Therefore, they have been slow to include them in the discussion around how to care for a patient. I think that is changing today, but engagement was slow at first.
Frankly, many health systems and health plans viewed the post-acute approach to healthcare as more occupancy-oriented than clinical care, but as they’ve engaged more with SNFs and others, they’ve realized that a tremendous amount of clinical care occurs in post-acute facilities, and that they sometimes represent the best opportunities for optimizing patient care and decreasing cost.
What role do you think SNFs should play in the value-based care landscape?
While I am seeing progress, we still need more SNFs to embrace being part of the solution! Raising their hands and saying, “You are asking for us to be more engaged. But don’t just treat us as a cost center whereby you are only trying to control our cost; instead, engage us as a critical part of the care continuum, give us a seat at that table, and you will see how we provide great clinical care.”
I think part of the conflict in the industry today is that so many relationships between acute and post-acute providers is still focused on cost containment. While that is one aspect of the triple aim, and certainly one aspect of value-based care, it is not the most important — the most important are the clinical outcomes!
Post-acute needs to shift the conversation to show value through care outcomes, and they need to show their active participation will reduce the ultimate cost.
That shift in dialogue is important because I think post-acute rightly say, “When I talk to a health system, an ACO or a health plan, they are primarily interested in reducing reimbursement or reducing cost. That should be secondary to the quality of clinical care that I can provide.” We need to reset that dialogue.
What do you think SNF operators have to do to get a fair financial reward in value-based care?
They have to participate in the discussion by creating active dialogues with health systems and health plans. Those are not simply about referrals or reimbursement, but also about making care better. One important step is sharing their data, joining the interoperability frameworks that exist today. One concern is increased scrutiny of their operations, but that is likely necessary for better alignment and better reimbursement with their clinical partners.
Is the shift to value-based care occurring fast enough, and does the pace of policy change align with the goals of that transition?
Most of us in the value-based care space would wholeheartedly say it’s not happening fast enough. If you look at the percentage of patients in value-based care arrangements versus more traditional fee-for-service, it’s still too small. But it’s not fair to our care providers, not just post-acute facilities, but also hospitals and clinics to say, “Listen, we need you to care about the total cost of a patient and follow these value-based care guidelines… while the majority of your revenue still comes from more traditional fee for service structures.”
In effect, it’s asking them to cannibalize themselves in the short-term for a far-off goal. The transition is not happening fast enough and there is conflict because of it. Fortunately, there are now more and more farsighted, VBC-reimbursement mechanisms that post-acute facilities can look into, like iSNPs, mechanisms that allow them to increase their value-based care footprint.
Ultimately, if providers focus on more collaboration, more visibility, more insights, shifting their model of care to reflect the demands of a value-based care world, they will be better positioned as more contracts shift to value-based constructs. Our job at PointClickCare is to give them the support and confidence they need to do this.
If you look at our recent initiatives, including a new network optimization module and investment in interoperability, we are focused on creating more visibility, more insights, more opportunities for intervention, so that our post-acute customers are comfortable taking more risk.
