Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Shared-Decision Making Advances Value-Based Care Outcomes

Achieving value-based care outcomes within a consumer-based landscape means making collaborative care and shared-decision making a top executive and provider priority.

Shared-decision making promotes strong dialogue between healthcare providers and healthcare consumers and builds stronger value-based care outcomes.

value-based care accountable care

At its core, shared-decision making gives beneficiaries more choice about their care and treatment options, thus advancing patient-centered results.

It also gives healthcare consumers more responsibility.

But with increased responsibility comes the choice to act – or not act – towards achieving desired value-based care outcomes.

"[Individuals] continue to have more responsibility for both the larger percentage and larger absolute value of their healthcare dollar,” David Josephs, Senior Vice President, Healthcare Solutions First Data Corporation, told RevCycleIntelligence.com.

"[We're] going to see payers continue to try to help doctors and hospitals and providers address the challenges associated with increased patient responsibility," he added.

Consumers engaged in open dialogue are more likely to take needed medications as directed, receive crucial screenings and immunizations, embrace an active lifestyle, and just take better care of themselves in general, reported the Brookings Institution.

But even the best communication efforts can fall apart.

Problems arise when a person’s health deteriorates because at least one party failed to truly listen.

Challenges exist from many interpersonal angles

Healthcare executives are apparently struggling to accommodate the patient as healthcare consumer, patient, and payer – especially within a value-based care environment.

According to research from the American Association for Physician Leadership and the Healthcare Financial Management Association, chief medical officers (CMOs) and chief financial officers (CFOs) reported “a lack of benefit plans designed to engage patients in their care and encourage shared decision-making” as a top concern.

CMOs and CFOs additionally noted patient accountability and responsibility efforts were lagging.

And they expressed overarching concern that lack of communication was to blame for making patients less responsible for their health outcomes.

Within a consumer-driven payment landscape, hospitals are nonetheless struggling to stay afloat.

“Hospitals have capital and human financial tied up in all kinds of software and regulatory initiatives,” said Ruby Raley, Associate Vice President of Product Strategy at Edifecs, to RevCycleIntelligence.com.

“They have the rising cost of pharmaceuticals eroding margins," she added. "They have the rise of consumerism."

But higher consumerism levels may be helping propel the healthcare industry toward greater value-based advancement.

“All of the new consumers joining the exchange are great for hospitals,” Raley stated. “It's really going to help many of them stay solvent and continue forward.”

As healthcare consumers continue to receive care under this widespread consumer-driven dynamic, they are increasingly struggling to pay their medical bills, especially as high deductibles only grow higher.

“Healthcare faces opportunity for improvement, particularly in the areas of performance outcomes and patient satisfaction,” confirmed the American Hospital Association’s Physician Leadership Forum.

“There are pockets of excellence and care models employed in the U.S. to be learned from.”

Three steps to promoting shared-decision making

Honing in on these pockets of excellence demands new strategies and focus.

There are three primary facets of shared-decision making that can be readily and openly adapted across the healthcare industry, according to Health Affairs.

“First, both the health care provider and the patient must recognize and acknowledge that a decision is, in fact, required,” the authors stated.

“Second, they must both know and understand the best available evidence concerning the risks and benefits of each option,” they recommended.

“Third, decisions must take into account both the provider’s guidance and the patient’s values and preferences.”

The authors advised involving other parties – well beyond physicians, nurses, dieticians, and pharmacists – in the greater shared decision making process.

“[Adopting] an approach that involves all team members in the shared decision-making process can further efforts to improve care coordination and reduce fragmentation by helping break down the silos that divide various health professions,” they added.

Shared-decision making improves patient outcomes

This kind of strengthened partnership may keep the shared-decision making ball rolling, especially given healthcare’s design.

Many different health insurance plans “have quality incentives or quality improvement programs that might be unique in some aspects but shared in other aspects,” Jennifer Chambers, Capital BlueCross Senior Vice President and CMO, told RevCycleIntelligence.com. 

“This type of collaborative raises the tides for all patients, and it also provides for that shared goal setting with all of the hospitals,” she added.

The overall shared-decision making process is particularly beneficial in the strengthening of palliative care initiatives across multiple settings, confirmed the Pew Charitable Trusts (Pew).

“Proactive [care] means not wondering why patients are non-compliant or non-adherent, but rather what is it about the care system that is not enabling them to take full advantage of it,” said Pew.

But as anyone with a fear of needles, blood, and beyond knows all too well, going to see a doctor is often a scary, anxiety-producing ordeal.

Patients may not be willing to openly communicate because they are just too intimidated to do so, said Chambers.

Further complicating matters is the fact that many patients are simply opting to stay out of the doctor’s office entirely as healthcare costs soar.

“The cost of health care has long been a concern in the U.S., on both a national and a personal level,” confirmed researchers with the Kaiser Family Foundation and The New York Times.

“For individuals, this concern plays out most prominently among those who face difficulty paying medical bills or who are unable to pay such bills at all,” they stated.

“[Even] a bill of $500 or less can present a major problem for someone who is living paycheck to paycheck.”

Limitations of a patient-centered approach demand addressing

Shared-decision making may help close these and many other gaps. For one thing, patient education is imperative.

Interactive patient decision aids – such as books, videos, and websites – may help patients make more intelligent, educated decisions during a physician consultation, Health Affairs reported.

But handing a patient a series of leaflets or referencing a series of website links to later peruse is far from a viable solution.

The art of how to communicate must not be overlooked.

“The challenge for medical decision makers and decision aid developers is to address the difficult question of whether, under what circumstances, and how patients should be nudged toward one option or another,” the report’s authors explained.

The most successful healthcare executives recognize the importance of a well-educated staff to help achieve this goal. Nonetheless, gaps need filling, and quickly so.

“[CFOs and CEOs] don’t listen to patients,” said Ginalisa Monterroso, CEO of Medicaid Advisory Group, to RevCycleIntelligence.com.

“There's just so much going on internally financially where they lose the person they need to focus on.”

Lack of staff training remains a top concern for healthcare providers, added Monterroso.

Matters of housekeeping on behalf of a billing staff may mean value-based care takes a back seat at times of critical patient need.

When patients walk in the door, they naturally have good questions about whether or not their health insurance is accepted, if their care delivery will be performed in-network, and what their copay amounts to.

But providers often struggle to deliver succinct, linear answers.

Even well prepared patients may have gathered information from a provider directory through the health insurance marketplace that is not correct.

Even though information is available online, it is perhaps updated too infrequently to keep up with live changes.

“Everybody's walking in with the wrong insurance. Everybody's walking in with the wrong drug coverage. What the executives are missing internally is that education component,” added Monterroso.

Health plans need to “improve their provider education processes to make sure network providers understand exactly which products they're participating in,” Brian Hoyt, Managing Director at Berkeley Research Group, told RevCycleIntelligence.com.

What impacts a health plan member most is physician participation with a particular health insurance product, he said.

“If a member needs to see a doctor and they go to their health plan’s provider directory and see a provider listed in the provider directory, there's a presumption that that particular provider is actually participating with that health insurance product,” stated Hoyt.

“If that turns out not to be the case, then that member could be hit with a bill for out of network charges.”

Hoyt advised that health plans either consider consolidation of offerings or take action to improve their provider education process to make sure even the most confusing, disorienting information is more clearly understood all around.

Keeping up with the evolving payment landscape

The assessment of accountable care organizations’ (ACOs) quality metrics is yet another challenge when it comes to the future advancement of shared-decision making opportunities.

“With a growing emphasis being placed on shared decision making, and patient engagement being measured as a critical component of ACOs’ quality metrics, ACOs will need an information technology infrastructure that allows for providers to effectively and efficiently communicate with patients,” reported the Journal of Managed Care Pharmacy.

Not many ACOs are practicing care team integration, researchers said.

A "troubling finding," researchers confirmed, is there are not enough protocols in place to communicate and efficiently handle adverse events.

Consequently, care quality may drop and value-based care outcomes may suffer accordingly.

“Without medication adverse-event protocols or clinical pharmacist integration into care teams, ACOs may lack the ability to ensure appropriate medication use and safety,” researchers claimed.

The role of the patient-centered medical home

But the creation of new ACOs alone is not enough to create actionable change.

Patient-centered medical homes (PCMHs) are gaining traction as a means of keeping care quality high and costs low.

Last year, the Affordable Care Act (ACA) provided over $35 million in nationwide funding for nearly 150 PCMHs.

“We need to change the way we pay for care delivery at the practice level,” Marci Nielsen, PhD, MPH, CEO of the Patient-Centered Primary Care Collaborative (PCPCC), told HealthITAnalytics.com.  

The PCMH model is effectively promoting more personalized coordinated care, she said.

“One of the first things patient-centered medical homes often do is bring a care coordination professional on board, whether that person is a social worker or a medical assistant,” she explained.

“That care coordinator is helping patients find the right person at the right time for their care needs.  That, too, leads to utilization changes that ultimately impact costs,” she added.

“Engaging with innovative payment models that reward the same activities the PCMH requires will help primary care providers make the most of both programs while ensuring that they are meeting the needs of patients requiring high quality, coordinated care.”

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