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Providers Will Need Quality Clinical Documentation Improvement (CDI) Programs to Make Value-Based Reimbursement Work and Provide Better Care

Crystal Morley - May 04, 2018

PHS-Blog-Value-Based-Reimbursement-Blog-Article-2-(PHS-8719)

Value-based care and the resulting value-based reimbursement may not have entered the day-to-day discussions of patients, but it's on the minds of nearly every payer and provider working to keep patients healthy at a reasonable cost.

It's here to stay because the intent is a noble one. Everyone agrees that better care at lower costs for patients is the right thing to do. The tricky part is getting there. Ask ten different people how to do it, and you might get ten different answers.

On one end CMS (Centers for Medicare and Medicaid Services) has moved to push value-based models that reimburse providers for the quality of care provided instead of the volume of services delivered. That's a dramatic shift by itself. At the same time, CMS also requires that providers improve the care provided to various patient populations. While CMS represents the most significant pool of patients in the U.S., most payers are following CMS's value-based reimbursement lead.

On the opposite end, the immediate impact for providers, both hospitals and physicians, is a potential decline in revenue. Lowering the volume of services billed means less money overall in the short term. Philosophically, providers can agree that reducing costs to patients while still providing better care is a good thing. After all, most doctors, nurses, and administrators went into the field of healthcare to help people. If they can keep patients healthier and happier, that's also a good thing. But how can providers make this shift happen in the real world and still generate enough revenue to survive? It won’t be easy, but quality CDI programs are a key component of the solution.

Most hospitals and inpatient settings have already made great strides in their CDI programs. They are adapting to capture the kinds of data needed for value-based care. They've begun to implement processes designed to accommodate severity of illness, risk, and mortality. The development of the All Patient Refined Diagnosis Related Groups (APR-DRG) has helped hospitals shift their focus to patient populations and be reimbursed based on of severity of illness. This change required inpatient CDI programs to ramp up to match. Accurate reimbursements required a complete picture. Without the extra detail, hospitals would miss out on critical revenue streams. 

The goal is healthier patients at less cost. Reaching that goal, and remaining profitable, requires providers to achieve clinical documentation consistency. All the chapters of the book have to demonstrate the quality of care given. Once individual stories are better documented, comparing the stories of patients with similar conditions over time expands the scope. Providers can identify trends for treatments that work or ones that need improvement.

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Posted in: Value Based Reimbursement, CDI, Clinical Documentation Improvement

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