Surviving Value-Based Purchasing in Healthcare: Connecting Your Clinical and Financial Data for the Best ROI

At first glance, creating a healthcare system that focuses on lowering costs seems counterintuitive in an environment that rewardsquality improvements. But lowering costs while improving quality and combining the two to ensure a thriving bottom line is precisely the challenge today’s healthcare finance executives face in the shift towardsvalue-based purchasing (VBP).

This two-pronged goal of lower cost and higher quality is, however, a winnable challenge, provided health systems have a thorough understanding of where they stand relative to clinical qualitymeasures以及与提供护理相关的费用。For finance executives, this understanding means factoring in clinical quality to predict the organization’sfinancial health, which is a significant paradigm shift from the traditional fee-for-service (FFS) reimbursement environment.

Under FFS, measuring volume was front and center for the finance team, and it’s still a key part of the equation today. Generally, healthcare has adapted to per-case payment methodology. But with payments also hinging on quality, focusing solely on old metrics (e.g., volume) won’t bring financial success, particularly in a world of accountable care, quality measures, shared savings, and bundled payments. Today’s focus must shift to lowering the costs while providing the highest quality care.

How Clinical Quality Measures Affect Finances

With the shift to VBP, the U.S. healthcare system faces its most significant transformation since the advent ofmanaged carein the 1980s. Health system financial executives are in the thick of navigating the complexities of this change, tasked with helping their organizations determine exactly how to strategically approach the new reimbursement environment.

Questions financial executives must address as organizations move towards VBP include the following:

• Do we want to participate in anAlternative Payment Model (APM)?
• Are we prepared to manage VBP partnerships? How will we collaborate with payers?
• What level of risk should we assume?
• 我们的组织在质量度量方面表现如何?与这些质量度量相关的奖励和惩罚是什么?
• What is the ideal financial arrangement for shared savings and how does it include quality metrics?
• Which regulations and quality metrics affect a hospital’s reimbursement (e.g., readmission rate, patient experience, hospital performance against others)?

虽然每一个单独的质量指标都是一个小项目来跟踪，但质量指标的组合加上新法规的涌入严重影响了底线。更复杂的是，质量衡量可以而且很可能会随着时间的推移而改变，每个付费方都有权将不同的惩罚和激励与之联系起来，跟踪就变成了一个非常复杂的命题。

Quality measurement is just one of the complexities that VBP introduces to the process of organizational cost management. Understanding how clinical quality and other factors affect the bottom line requires financial executives to master the new lexicon, which pays and rewards providers based on outcome quality and patient satisfaction. Volume metrics alone can’t provide the insight organizations need to succeed under healthcare reform. Finance teams need to work with quality teams to develop dollar impact and prioritize which metrics to track.

Financial Metrics for Value-Based Purchasing

为了做出合理的决策，财务主管需要在VBP中跟踪除音量外的关键指标，以全面了解卫生系统的质量。这些指标包括:

• Throughput: Throughput, the time it takes to complete a process, now translates directly into money, and greatly affects quality (e.g., the average wait time in the emergency department, time between cases in the operating room, turnaround time for labs). With VBP, improved throughput will benefit the organization in two key metrics: reducing cost and increasing patient satisfaction. There are no incentive dollars attached to these measures.
• Quality: VBP requires hospitals to assess and report quality measures relative to defined benchmarks, and those not reporting quality metrics are subject to penalties. CMS, which began itspenalty and incentive periodfor VBP in 2013, judges hospital performance on both achievement relative to the national benchmark and improvement relative to prior score. Defined metrics fall into the following four categories with each weighted 25 percent in the program:
  • Clinical quality.
  • Engagement (experience).
  • Efficiency/cost.
  • Safety.

The CMS VBP program is self-funded via hospital eligibility for a penalty or a bonus for its scores in the four categories above with a cap of 2 percent.

Organizations should prepare to answer key metrics and determine who is accountable for results—including mortality rates for specific conditions, patient receipt of discharge instructions, and complication rates for hip/knee arthroplasty cases. Additional notable metrics should include the facility’s patient engagement score and rate of hospital-acquired infections.

The following measures also impact VBP:

• Readmissions: CMS will base quality assessment on the rates of readmissions for all causes within a certain period for specific patient populations. For example, what are the rates of heart failure, pneumonia, COPD, total hip and knee arthroplasty, and acute myocardial infarction and coronary artery bypass graft readmissions within a 30-day period? In 2013, Medicare began enforcing penalties for30-day readmissions. The hospital can receive a 0 to 3 percent maximum penalty as a reduction of operatingMedicare Severity-Diagnosis Related Group (MS-DRG)payments.
• Patient experience:Patient experience这不仅仅是一个关注和目标，因为它现在与付费模式直接相关。病人对他们的护理经验有多满意?房间还满意吗?家庭舒适吗?他们会推荐那家医院吗?在医疗保险以价值为基础的支付系统中，对患者体验的关注是一个关键指标。经验指标包括医院、医生和APM(替代支付模型)。
• Cost-per-episode of care:Containing costs is now more important than ever, as VBP systems strive to keep treatment consistent and expenditures appropriate and predictable. Health systems must consider the costs of the individual components of care, the episode across the continuum of care, and which clinical processes have the greatest cost variation. Reducing this variation will improve the cost structure. Plus, in 2015, CMS adopted a new measure—Medicare Spending per Beneficiary. This report shows total spend for Medicare beneficiaries for 3 days prior to admission, admission, and 30 days post admission by claims type compared to state and national averages. This information also provides the scoring for the efficiency/cost measure in VBP.
• Hospital-acquired condition (HAC): TheHACprogram encourages hospitals to focus onpatient safetyand reduce infection rates. CMS measures patient safety by thePatient Safety Indicator (PSI) 90评分和导管相关性尿路感染、中心静脉血流感染、耐甲氧西林金黄色葡萄球菌、艰难梭菌和手术视力感染的发生率。得分最低的百分比的医院将获得1%的MS-DRG支付减少。
• Screenings, immunizations, other clinical measures:CMS uses these measures in theirMerit-Based Incentive Payment System (MIPS)forMedicare Part B供应商和ACO质量评估。这些措施侧重于预防保健和慢性保健管理，以鼓励提供者监测特定领域，如控制抑郁症、高血压和糖尿病。

Each of the above metrics carries potential penalties and/or incentives under the various CMS-sponsored payment innovation programs. Commercial payers have implemented similar programs to track quality metrics that impact the health of their insured members. These programs increase the number of measures organizations must monitor and improve.

Commercial payers rely onHealthcare Effectives Data and Information Set (HEDIS)一套标准的绩效指标。在基于价值的环境中茁壮成长的组织将常规地跟踪这些措施，作为他们报告和监控结构的一部分，而不是赞助他们在这些领域的表现的偶尔研究。

The COVID-19 Impact on Quality Measures

Beginning in 2020, theCOVID-19public health emergency has impacted quality measures. In response, CMS has finalized ameasures suppression policyto ensure providers are not penalized based on pandemic-affected data. CMS has revised baseline periods, excluded COVID-19 patients, and suspended measures temporarily.

2022年，CMS将不再对VBP项目中的医院进行支付调整。CMS将展示公众消费的措施。In 2023, CMS will suppress the measure forPSI 90 and pneumonia mortality. Also in 2023, CMS will eliminate the pneumonia readmission score and remove all COVID-19 patients from the remaining readmission measures. The agency will adjust the performance periods in the HAC program by truncating the periods for reporting in 2022 and 2023.

Translating Clinical Quality Metrics into Financial Terms Begins with Data

随着临床质量指标对组织的底线产生越来越大的影响，医疗保健财务主管面临着新的挑战:如何跟踪、度量和分析这些指标，并将其转化为财务术语?答案从数据收集开始。然而，使用数据并不像听起来那么简单。Significant barriers, such as the following, exist to leveraging data effectively to drive value-based decision making:

Barrier #1: Financial and Clinical Data Siloes

传统上，独立的系统包含财务和临床数据，使相关数据只对需要它的团队(例如，账单和临床护理团队)开放。因此，财务数据往往远离临床数据，很难理解两者之间的关系。此外，许多医院和卫生系统在整个护理连续体中都有各种各样的事务性系统竖井。

While numerous health systems have made headway in aggregating their clinical data to create longitudinal health records, the unstructured nature of clinical documentation (e.g., manually reviewing charts) often hampered efforts to track metric. Plus, clinical data aggregation alone does not incorporate the financial, operational, and patient-experience data an organization needs to fully visualize its quality/cost equation.

Barrier #2: Outdated Reporting Processes

Healthcare data收集和报告过程往往是过时的，对于基于价值的环境的复杂性来说是不够的。例如，质量团队可能提供关于再入院、HACs和临床过程的核心度量，而财务负责成本和支付数据。Getting data from both parties may become a manual collection process.

The following are two significant drawbacks of outdated data gathering and reporting processes:

#1: Inefficient data collection that doesn’t scale

A typical scenario for gathering data for analysis may comprise the following five steps:

1. Hospital executives determine a need for data to track strategic and operational goals.
2. The finance/planning team outlines the metrics it needs.
3. Analytics teams gather data from the individual teams who regularly maintain and report on it.
4. Analytics teams assemble collected data based on a prescribed reporting calenda.
5. Analytics teams return data to executives via a dashboard.

While digitized dashboards are convenient for executives, they require significant amount of manual work to pull the information together, which slows the process and leaves reports further from real time. Furthermore, analytics teams must update these reports on a regular basis.

Some health systems have adopted dashboard programs for point solutions that remove some of the manual effort. While these dashboards may provide insight about a targeted issue, they don’t link clinical, financial, operational, and patient experience data in the way that value-based decisions require. Because the solutions aren’t linked, individual users still must determine how to fit these reports together and make collective sense of them—in other words, dashboards lack the ability to drill into data and ask questions.

#2: Inconsistent data without a single source of truth

When team members throughout the organization access data in different ways and from multiple sources, inconsistency and variability among the data are common. For example, for two executives may present conflicting data about emergency department admissions or length-of-stay trends simply because they relied on different data collection methods. Inconsistencies like these can lead users to distrust the data. And of decision-makers don’t trust the data, they can’t be sure they’re making the best decisions for the organization.

Making the Data Work

To overcome data trust challenges and successfully manage costs in a value-based environment, health systems can leverage their two most important assets for effecting cost and quality change: data and clinical teams. Finance executives provide leadership to actively assist in this effort.

The Data, People, and Process Solution

The keys to successfully navigating the quality and cost demands of value-based care are as follows:

• Aggregating and analyzing data from source systems throughout the enterprise.
• 建立由临床医生、质量人员、分析师和技术人员组成的永久一线团队，由财务分析师支持。
• Empowering the above teams to link clinical and financial data to guide and realize improvement.

Liberate and Aggregate Clinical and Financial Data

基于云的数据平台，如Health Ca世界杯厄瓜多尔vs塞内加尔波胆预测talyst数据操作系统(DOS™)是解放临世界杯葡萄牙vs加纳即时走地床和财务数据并将其连接在一起以获得全面趋势和机会的关键。

在以价值为基础的环境中，一世界杯厄瓜多尔vs塞内加尔波胆预测个有效的平台可以汇集来自各种来源的数据。它必须适应组织试图影响的项目所涉及的所有临床和财务数据表。The data platform also needs to include information from costing systems, including supply chain and labor productivity to calculate the true cost of an episode of care

Using Clinical and Financial Data Effectively to Drive Sustainable Improvement

With the data in hand, health systems must then determine how to use that information to meet cost and quality goals. Most organizations employ a top-down approach for driving change that relies on executive dashboards. However, multidisciplinary, permanent teams operating on the front lines of clinical care and using clinical and financial data to drive improvements support a more effective bottom-up approach.

Problems with the Top-Down Approach to Data-Driven Change

卫生系统通常采用的自上而下的方法是，使用管理指示板根据机构、部门和个人相对于定义的基准的表现对其进行排名。这种方法的运作基于这样一个假设:来自高层的压力将推动变革。However, a top-down strategy has several key drawbacks:

• 来自执行指示板的数据和见解可能不会显示与临床工作流程指示板相同的数据。当组织不分享自上而下的仪表板指标时，他们只会让临床医生感到担忧和分心，而不是改善护理。消息传递中的一致性是获得数据信任的关键。
• Dashboard summaries can be incomplete and often omit key measures needed to improve a clinical process.
• Executive priorities as defined on the dashboard may not match frontline clinical needs. Metrics and mandates that come from the top don’t always account for the realities of the care process.
• 自上而下的方法可能会引发轻率的反应，而不是推动根本原因分析和可持续的变化。更好的方法是让临床医生参与到一个积极主动的团队过程中来进行改进。与临床团队和整个组织共享具有高级目标的仪表板，以在所有级别上对齐目标，增加了实现这些目标的可能性。仪表板的关键标准是透明度。

Building a Team from the Bottom Up to Drive Change

组织可以通过形成多学科的、永久的、一线的团队，利用聚合的临床和财务数据来推动可持续的改进。这些一线团队由临床医生、质量人员、分析人员和技术人员组成，并得到财务代表的支持。这种方法利用一线人员来推动质量改进。

一线团队是质量倡议的掌舵者。为了真正有效，团队需要向由管理成员组成的指导团队报告，他们可以消除障碍，优先考虑工作努力，并为整个组织设置明确的目标。The frontline team—those who are closest to the processes that need refinement—have the following responsibilities:

• Analyze the data确定目标和如何最好地实现改进。团队一起工作，确定如何改善某些结果，团队对此负责，使用组织的目标作为指导，并实施他们认为最有效的协议。
• Continually monitor goalsto ensure the team focuses on sustaining quality and financial improvements and clinical and operational outcomes. This type of grassroots-change pathway empowers the entire team to identify opportunities for improvement, while also demonstrating exactly how the quality/cost equation improves through these efforts.

Turning the Tables: Getting Clinicians to Understand Finance

Just as finance needs to understand the impact clinical processes have on the bottom line, clinicians need to also understand the financial implications of their clinical decisions. Organizations involve clinicians in looking at both clinical and financial data by creating a learning culture in which clinical and financial personnel listen to each other and educate each other.

Integrated data informs this level of collaboration, enabling a health system to effect sustainable improvement in a value-based environment. Finance personnel present data to the clinical team to educate them on what the financial data means. Then, the clinical team can help define how to best adapt care to improve outcomes and lower costs.

For example, financial analysts can use data to show clinicians the variation in how they are delivering care at different locations using tools like the bubble chart in Figure 1.

图1中的每个气泡代表一个位置，气泡的大小反映了提供者在特定患者群体中处理的案例数量。根据所治疗病例的严重程度显示每个病例的费用变化。注意到每个病例的成本变化，数据表明有机会研究临床表现和应用经验教训，以提高质量和成本。

Presenting visually accessible data to clinicians can prompt productive discussions about which treatment protocols offer the best outcomes for patients and whether the care delivered was truly indicated. Together, clinical personnel can then determine what care they can standardize, and which costs they can reduce. Finance can model the change and share the expected results with the larger team.

除了有效的数据共享，一线团队必须是长期存在的，不能在实现目标后解散。组织需要不断地将团队合并到其结构中，以便在持续的基础上监视度量。团队必须有能力和责任根据需要做出改变，不断改善护理。如果没有持续不断的质量监督和成本衡量，收益可能会开始下降。

Embracing Quality as a Key Financial Resource

随着行业向VBP发展，财务主管必须转变模式，将数量护理和质量护理作为确保组织财务健康的关键资源。财务和临床人员的有效合作，以及敏捷的数据平台，在新的基于价值的范式下，为财务成功创造了一条清晰的路径。世界杯厄瓜多尔vs塞内加尔波胆预测

Additional Reading

Would you like to learn more about this topic? Here are some articles we suggest:

• From Volume to Value: 10 Essential Strategies for Navigating the Healthcare Shift
• Value-Based Care: Four Key Competencies for Success
• 用健康催化剂价值优化™解决方案拥有基于价值的护理未来世界杯葡萄牙vs加纳即时走地
• The Key to Transitioning from Fee-for-Service to Value-Based Reimbursement
• Shifting to Value-Based Care: Four Strategies Emphasize Agility