The transition from a fee-for-service to a value-based payment model that rewards providers for favorable outcomes may be the most significant challenge healthcare has faced. Value-based care and the corresponding value-based reimbursement strive to reduce the costs of healthcare while at the same time improving care for both individual patients and entire patient populations. That's a tall order.
It's no secret that Clinical Documentation Improvement (CDI) programs are a critical component of value-based reimbursement. After all, it takes better documentation to demonstrate better quality care and get paid appropriately for it. The challenge facing everyone is making value-based reimbursement work in a practical setting. On the surface, it seems that everyone involved is in opposition. If we dig a bit deeper, we find that may not be the case.
Despite first appearances, CMS hasn't hung providers out to dry. The value-based reimbursement models established by CMS create room for providers to improve revenue to different degrees. Diving into all those models, how each is different and the pros and cons of each is another article for another day. All the models do share a common trait. Providers that deliver exceptional, efficient care have the opportunity to either earn higher reimbursement rates or share in the savings they generate.
The key for providers to earn more and provide better care is data.
Patient data from clinical documentation to be exact. This information includes both the complete story of individual patients and corresponding trends across patient populations over time. Getting this information right makes CDI programs that perform a priority that providers can’t ignore.
Assembling that data to paint a complete picture before, during, and after patient care is a process that every provider is now working to tackle. Shortcuts to reach reimbursement opportunities won't work. Omitted or inaccurate chapters can put patient safety at risk, and that is the opposite of what value-based care aims to achieve. Telling the entire patient story is the only way to show the quality of care provided.
The truth is we are all still learning how to make value-based reimbursement work in the real world. It will take time and a lot of hard work by everyone involved. Healthcare in the United States is a behemoth industry that is slow to change even when that change is a good one.
The jury is also still out on which value-based reimbursement approaches will work best. The answers are a work in progress. One thing, however, is clear. Data is a critical factor used to determine value-based reimbursement rates, and that means CDI, both inpatient and outpatient, will play a pivotal role in the creative solutions that lead to success.
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