The shift from fee-for-service systems, which reward providers of high utilization, to a value-based payment system, rewarding high quality, cost-effective care, bridges multiple gaps which have been inherent between health plans and providers in the authorization of Applied Behavior Analysis services for autism.
By supporting and incentivizing attainment of key quality indicators, health plans create the best opportunity for both member progress/success in treatment and cost saving, which translates into better outcomes for all involved (payor, provider, and family).
Empowering Providers to Deliver High Quality Care
For a value-based payment system to be effective, providers need to embrace the process, demonstrate best practice, and coordinate care for improved outcomes. The key to a successful system is developing provider trust through data and information transparency, to create a cohesive and productive partnership, where high quality of care is a shared responsibility and focus.
By outlining a standardized measure of care, sharing evaluation tools and documentation, monitoring for consistency in utilization and quantifying areas for performance improvement, a symbiotic relationship is formed.
This relationship allows for successful collaboration between health plan and provider, implementation of individualized case management and aggregation of data to show trends for improving member experiences and reducing costs through population health management.
Consider the Following
Given the wide array of symptom severity within the realm of an autism diagnosis, it may be detrimental to build a value-based care model on things, such as a percentage of goals mastered with hours authorized. This situation does not reinforce person centered care, punishes providers who treat the most severely affected members, and disregards the importance of utilizing social determinants of health in making care decisions.
Where to Start?
The key to transforming the payment system is transparency.
Using a standardized review process, where the provider is aptly aware of the measurement criteria, resource needs, and coordination of care between providers/caregivers creates an actionable member record to tend for member improvement and the ability to reduce cost as member experience improves.
Using clearly outlined quantifiable quality indicators, the provider is enabled to show levels of quality care. Take the following indicators into account:
- Coordinating care with other service providers
- Identifying resource needs
- Attempting to overcome treatment and progress barriers
- Consistently using appropriate outcome and curriculum-based measure
- Accounting for client dignity
- Submitting appropriate data for goal consideration
- Showing social determinants of health
- Implementing caregiver training, maintenance, and generalization of skills
Implementing a standardized tool for utilization management review, where the algorithm identifies and weighs factors affecting care progress ensures the provider is aware of how their pay structure is constructed, creates consistent measures of quality, and builds an integral focus on supplemental resources, which all pave the way for increased gains within treatment and quality of life for the member and family. This is the ultimate goal for payors, providers, and families.
Technology tools which provide analytics and show possibilities for process improvement improve care quality and implementation.
For more information on how RethinkFutures’ Clinical Decision Support solution can help accelerate your plan’s transition to value-based care, please contact us.
