Value-Based Care: Accelerating adoption in the Middle East

All over the world, value-based care (VBC) is gaining momentum as an innovative model to organize health care delivery, ensuring better returns on spending coupled with higher patient satisfaction. Juan Montanez and Annie Mayol from FTI Consulting walk through the pillars of value-based care, and how it could help revolutionize healthcare systems in the Middle East.

The transformative journey of many GCC countries, driven by visionary agendas, remains strongly on course. The impact of these national masterplans on the healthcare system will be dramatic, with major investments aimed at improving healthcare quality and efficiency, promoting preventive care and wellness, expanding capacity and bolstering the healthcare workforce all while achieving financial sustainability.

Integrating value-based care into the healthcare masterplan could provide a critical contribution to the overall strategy.

Value-based care is an approach to health care management and delivery that represents a true paradigm shift, with value defined as achieving the greatest possible return on healthcare spend. To that end, VBC emphasizes:

• Proactive management of a population’s health conditions and social risk factors;
• Restructuring of care delivery systems to ensure focus on wellness, prevention and the highest-impact interventions – the right care by the right provider at the right setting;
• Systematic measurement of outcomes and costs;
• Alternative payment models (APM)s: provider compensation methodologies that promote efficiency and results instead of volume; these models fall within a spectrum of risk assumption on the part of providers.

Although value-based care is seen as an imperative across the globe, recent studies found that VBC adoption has been slow and halting, with providers struggling and/or hesitating to transition from traditional models of delivery and compensation.

At FTI Consulting, we believe that successful VBC adoption necessitates changes in how healthcare organizations perform and manage critical functions that fall under three broad categories:

Clinical & Service Integration

Success in value-based care requires process integration and information integration both within health care delivery systems and – in order to effectively tend to social risk factors such as lack of transportation, inadequate housing, and “food deserts” – across a wide array of human services organizations.

Organizations that succeed in VBC implement, harmonize and continuously optimize operating protocols, organizational structures and information systems to achieve high levels of integration across the entire service continuum.

Population health is “the health outcomes of a group of individuals, including the distribution of such outcomes within the group”. Healthcare costs are concentrated, with multiple studies demonstrating that a relatively small percentage of individuals – usually 20 percent or less – account for a majority – usually 50 percent or more – of healthcare spend. The number and severity of chronic conditions is a predictor of costs, which are somewhat persistent from year to year.

The key to effective chronic care management is risk stratification, proactive intervention and effective management of care transitions.

Provider engagement is critical to succeeding in value-based care, yet engagement is lagging. According to a Care Allies-Modern Healthcare Survey, only 23 percent of respondents said most physicians are engaged with their organization’s value-based care strategy, with 27 percent stating that about half of physicians are engaged . Physician alignment with the organization’s VBC goals, expectations, measurement and compensation is essential.

Operations

Organizations engaged in value-based care require strong governance and compliance programs, analytics and operational processes, that are underpinned by interoperable, accessible information systems that deliver digestible, actionable information to the right user at the right time.

Member engagement requires self-management and supportive provider and/or payer interventions. Patients (and their caregivers) need to be active participants in optimizing their own care inclusive of changes in lifestyle, treatment (drug) adherence, condition monitoring and intervention. Mobile applications, remote monitoring, smart home sensors and telehealth have become widely available and increase engagement.

To fully leverage these technologies, patient skill levels and confidence need to be raised to improve management of health problems.

Analytics support the “Triple Aim” and are used for identifying the highest cost and risk patients (i.e. risk stratification), monitoring performance and variation, enhancing quality, assessing risk-adjusted resource utilization and measuring the experience of care.

Beyond analytics, information technology uses in healthcare are advancing at a remarkably rapid pace – interoperability, cloud computing, remote monitoring, mobile applications, artificial intelligence/machine learning and deep learning (neural networks) have entered the healthcare vernacular.

We believe that fully exploiting healthcare data is the next frontier. For instance, at the University of California San Francisco investigators have used big data extracted from electronic medical records to document pharmaceutical treatment variation in Type II diabetics and match that variation to outcome measures.

Healthcare risk management encompasses processes and systems used to uncover, mitigate, and prevent risks in healthcare organizations. Originally focused on patient safety and medical liability, risk management now extends to strategic, operational, technology and financial risk, the latter given the advent of VBC and the transfer of risk to providers.

Strategies to manage financial risk include appropriate coding of patients, a high recapture rate and processes of care focused on prevention, proactive intervention, transitions of care and a reduction in emergency department visits, hospitalizations and re-admissions.

Financial Performance

Success in value-based care requires a continuous focus on balancing financial incentivization with the right degree of risk tolerance, organizational readiness and compliance.

Actuarial services enable providers to make data-driven decisions, manage financial risk and optimize the financial performance of their organization. Sustainable price setting is based on demographics, market trends, medical utilization, and claims history.

Actuaries determine the appropriate level of reserves based on historical claims data to cover potential future claims, and risk mitigation strategies such as reinsurance may be required. They also generate longer-term financial projections, ensure regulatory compliance (e.g. actuarial standards, financial reporting and documentation) and contribute to the design and evaluation of health plans offered by a subset of providers.

Compliance is a strategic function necessitating a culture of integrity, encouraging employees (and others) to report potential violations. A proactive compliance program consists of the following components: written policies and procedures, training and education, regular monitoring and auditing, reporting and investigation, corrective action, non-compliance risk assessment and a code of conduct.

Conclusion

Value-based care is here to stay, gaining momentum and increasing in importance. We strongly encourage healthcare organizations across the Middle East to embrace VBC by deploying the right infrastructure and best practices.

About the authors: Juan Montanez is Senior Managing Director at FTI Consulting, where Annie Mayol is a Managing Director. FTI Consulting helps healthcare organizations – providers, private sector payers and government agencies that regulate the provision of healthcare services – all over the world with designing value-based care and accelerating its adoption.