Moving Toward Value-Based Care — What It Means for Social Work
Providers and payers are gradually shifting to a value-based model to lower costs and improve health outcomes. How will social workers figure in the transition to care based on quality vs. quantity of services?
“The United States has the highest costs for health care of any industrialized nation and some of the worst health outcomes,” says Geoff Wilkinson, MSW, a clinical associate professor at Boston University School of Social Work. And he’s right.
Despite the fact that Americans receive a similar amount of health care services annually when compared with other high-income countries, the cost is much greater. However, the results do not align with that price tag. Comparatively, U.S. health outcomes are lower than those of other industrialized countries.
While there may be several reasons for the discrepancy, health care and public health professionals recognize that the health care system needs to be improved on many levels. One such solution lies in how providers are paid for their services.
Increasingly, providers and payers are looking to a value-based payment and care model—a model that differs significantly from the traditional fee-for-service paradigm.
Wilkinson adds that, in value-based care, the “risk is being shifted onto the providers, from the payers. The providers will be responsible for the risk of inappropriate or ineffective care. The cost incentives will be to have healthier patients. If there are savings to be had in their approach, the providers will be able to share in those cost incentives.”
To best explain how care under a value-based model might differ from the more traditional model, Pierce-Wrobel describes a standard labor and delivery room. Traditionally, when a woman gives birth, she does so lying on a bed on her back. The medical providers assist her as they sit or stand upright, comfortably ushering the infant into the world. In this scenario, everyone is comfortable except, perhaps, the woman. And in fact, there is evidence that suggests lying down to give birth is not the most beneficial position to the woman, the child, or the task at hand.
“In a more value-driven, patient-centered model, the delivering moms can be much more upright, in water baths or in a more comfortable position. It’s placing higher value on the experience [for the patient],” Pierce-Wrobel says.
When providers bill for services under a value-based care model, they are able to bundle treatment as a whole rather than parse them out individually. How exactly that may look depends on the type of value-based model used but may mean that a provider is paid for an episode of care, such as a hip replacement and any complications that may stem from it, for meeting quality and efficiency benchmark measures, or for a coordination of care.
“Both patient-centered medical homes and accountable care organizations employ value-based care models of service delivery, wherein all team members are incentivized to improve access to care, quality of care, and patient health outcomes while reducing costs,” says Abigail M. Ross, MSW, MPH, PhD, an assistant professor at Fordham University Graduate School of Social Service.
Utilizing this model means that a provider is reimbursed for a specific action, such as a physical exam, a blood test, or an hour of therapy. Each individual service is billed on its own rather than in terms of how it benefitted or served the patient’s need.
“The traditional fee-for-service payment model does not utilize a bundled payment structure; instead, it reimburses health care providers based on the number of patients seen, services provided, tests completed, or procedures conducted,” Ross says. “This structure rewards individual providers for both the volume and quantity of services provided—which is often characterized in health care settings as ‘productivity.’”
What is missing from fee-for-service is an acknowledgement of the quality of care. When providers only have to account for the action, the outcome becomes less important.
“As a result,” Ross says, “patients are either rushed through their visits quickly to make time for providers to see more patients, or, on the other hand, are subjected to excessive delivery of expensive care. Either way, there is more room for patient outcomes to take a backseat to profit margins in the [fee-for-service] model.”
Though common, the fee-for-service model is increasingly being seen as an ineffective model in terms of health and well-being not only for the individual but also for society as a whole, part of the reason the United States currently has the highest health care costs and worst outcomes of any industrialized nation.
The Affordable Care Act (ACA) recognized this and included provisions about how health care is delivered and paid for, emphasizing the importance of value over quantity. For example, the ACA instituted a penalty on hospitals paid under the Medicare Prospective Payment System that had excessive readmissions. Ultimately, if a hospital had a higher-than-average number of patients returning for care, their payments would be lowered, incentivizing the hospital to ensure discharges were appropriate and patients had the care they needed in the hospital and in the community.
With the implementation of the ACA, as well as the understanding that fee-for-service is not best serving patients, many have begun shifting or at least considering moving their reimbursement models toward a value-based structure.
For one, employing a value-based model allows the providers to expand their focus and reassess how they provide treatment. “Value-based payment models give providers the ability to innovate, reduce unnecessary services, and reinvest in services that matter to the patient,” says Joe Pyle, MA, president of the Thomas Scattergood Behavioral Health Foundation. “It frees them from worrying about whether a needed service fits the confines of a CPT [current procedural terminology] billing code and allows them to focus on getting the right services to the patient at the right time.”
Additionally, value-based models support other trends in health care delivery that take a more holistic view of the patient, such as care coordination/integration.
“It requires better care coordination,” Wilkinson says. “Is it adequate for the system to document that the physician made the referral? No. How does the system document whether the patient used the referral, whether the [referred] provider actually scheduled and saw the person? What happened as a result?”
This is the opposite of what fee-for-service models encourage, Ross says. “Because each provider is required to bill individually [in fee-for-service], the model actually disincentivizes team-based care and the provision of preventive services,” she says. “Value-based care reimburses for both team-based care and preventive services, which include both early detection and intervention. Intervening early often leads to better health outcomes, as well as lower costs.”
Furthermore, a value-based model allows for the patient to be an even more integral part of the care team. In essence, it promotes patient-centered care.
“One of the questions that a value-based delivery system asks of its patients is to be true partners in shared decision making about their care. It needs to be led by patients and their level of comfort,” Pierce-Wrobel says.
For best outcomes, providers also must learn about and consider more than the patient’s physical or behavioral health diagnosis. They must address environmental, socioeconomic, and related factors that influence population health outcomes more significantly than the availability of medical care. These social determinants of health, according to Healthy People 2020, are the “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks” (Healthy People 2020, n.d.).
Wilkinson notes that the move toward value-based care is encouraging providers to screen individual patients and arrange referrals for nonmedical, health-related service needs involving food security, housing stability, utilities, transportation, and interpersonal safety. “These are promising steps toward prevention and moving care ‘upstream,’” he says, “but in order to truly address the social determinants of health and promote health equity, action needs to be taken on a larger scale, not patient by patient.”
Social Workers on the Team
“Currently, providers are stuck trying to figure out how to weave together a patchwork of regulations and billing codes that vary by each payer to simply provide integrated behavioral and physical health services,” says Robert Ferguson, MPH, director of government grants and policy at the Jewish Healthcare Foundation. “Well-designed value-based payment models eliminate this confusion.
“If a primary care practice receives a per-member-per-month or episode-based payment rate that is affected by quality measures, such as depression screening and depression remission, then that primary care practice is freed up to figure out how to design their team roles and workflows with behavioral health care managers and consulting psychiatrists,” he says. The same is true for behavioral health care providers. If they have a payment model that includes physical health measurements, they can incorporate the appropriate professionals into their teams.
“In the current payment system, we have placed providers in a box that is defined by regulations and by what is and what is not billable,” Ferguson says. “Value-based payment models create an opportunity to break out of this box.”
By expanding the teams, social workers specifically can find a more prominent seat at the table in settings where they may not have had that position before. The skillset that social workers have and the scope that the profession takes are directly in line with the goals of value-based models.
“Social work is well positioned to play an increasingly significant role in improving people’s health through prevention, integrated health care, and improving the social determinants of health,” Ross says. She cites a 2018 systemic review in which it was found that the presence of social workers as leaders on clinical health service teams provide an added benefit that teams without social work leaders do not see.
“There’s a challenge in transitioning away from [fee-for-service]. You can’t exactly shut down the whole health system. Transition has to happen over time,” Pierce-Wrobel says. “When only a small portion of your contracts are tied to value, the majority of reimbursement is still tied to volume. It can be really hard for providers and payers to justify the kind of investments needed.”
An added challenge stems, for some, from simply being a behavioral health care—as opposed to primary care—provider. In general, behavioral health care providers have been slower to transition away from fee-for-service. One of the reasons behind this lag is that the behavioral health care providers have more of an uphill battle when it comes to the reimbursement structure.
“There’s a lot of disparity in the way that behavioral health services are reimbursed or carved into traditional health plans,” Pierce-Wrobel says. “They are already starting off with a somewhat disconnected reimbursement model.”
Ferguson agrees, noting that “compared to physical health providers, there are fewer opportunities for behavioral health providers to transition to value-based payment models.”
This is due in part to generally poor integration of behavioral health and physical health care in the U.S. health system. “The ACA made major strides in improving access to behavioral health services,” Wilkinson says, “but achieving legally mandated mental health funding parity is still a work in progress.”
Once transitioned, providers must determine how best to allocate their time and resources, and be prepared for the reality that not every action will immediately result in an outcome. For example, if a care team realizes that a patient is regularly hospitalized in the summertime because they have asthma and lack an air conditioner, purchasing that air conditioner won’t immediately result in a change.
The care team would look for a way to secure the air conditioner for or with the patient. The value-based repayment allows the team to think outside the box and have a social worker or case manager on the team who can help the patient with that task. The challenge in it is that such an action might not have an immediate return on investment. The better outcome down the road would be where the value is found. It won’t be until the next summer when the patient is not readmitted that the outcome will be realized, Pierce-Wrobel says.
“You are looking for a longer-term return on those investments,” she says. “That can be hard when you need to report earnings on a regular basis.”
And that ability to wait for the return, again, requires time and resources.
But that does not mean the members of the health care system are balking at the idea. Instead, many are working diligently to make value-based care the more prominent model in health care. When they reach their goal, patients will ideally have access to services in which quality trumps quantity.
— Sue Coyle, MSW, is a freelance writer and social worker in the Philadelphia suburbs.
Rama, A. (2017). Policy research perspectives: Payment and delivery in 2016: The prevalence of medical homes, accountable care organizations, and payment methods reported by physicians. Retrieved from https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/public/health-policy/prp-medical-home-aco-payment.pdf.