According to a recent study in the International Journal for Quality in Health Care, “what cannot be measured, cannot be improved.”
With detailed digital data available just a few clicks away, non-profits are being held accountable for measuring their service outcomes. In fact, all organizations seeking to gain and maintain accreditation are required to record and report outcome statistics as part of their performance improvement programs.
For example, while The Joint Commission has always required organizations to assess outcomes of care, treatment or services, organizations are now required to accomplish this through the use of a standardized tool or instrument. By utilizing “measurement-based care,” The Joint Commission “believes these standards enhancements will help accredited customers meet the growing demand to demonstrate the value of their services and increase the quality of the care, treatment, or services they provide.”
For health and behavioral service providers, the focus on process – or fee-for-service arrangements – is obsolete: the new priority centers on positive patient results, which must be documented.
This approach rejects fee-for-service reimbursement, where “individual providers are incentivized to order more tests and procedures and manage more patients in order to get paid more, regardless of patient outcomes,” according to the New England Journal of Medicine.
Value- and performance-based models aim to rein in ballooning costs. The outcome-based orientation is partially designed to help lower spending.
Another broad goal is to improve care and help patients efficiently navigate the health care system. Collaboration and customized services are replacing the top-down model, where experts determine the procedures and patients follow along.
Many major insurance companies are reorienting their reimbursement schedule to reflect this data-driven model. According to national accrediting body CARF, Cigna, Aetna and U. S. Healthcare plan to increase value-based payments to as much as 90 percent of all reimbursement spending in the next few years.
Beyond private insurance companies, state and federal mandates are also pushing patient care toward outcome-based services.
The Centers for Medicare & Medicaid Services (CMS) has begun implementing value-based changes, for example. Under Section 223 of the federal Protecting Access to Medicare Act, moreover, the Substance Abuse and Mental Health Services Administration initiated a pilot program in eight states to introduce value-based outcomes in certified community behavioral health clinics.
The program includes technical specifications and data-reporting templates requiring the collection of 21 measurable data points.
Participating states are mandated to “collect and report on encounter, clinical outcomes, and quality improvement data,” according to CMS. “The statute also requires annual reporting by the states that will entail collection of data which can be used to assess the impact of the demonstration program.”
In addition, fee-for-service reimbursement is being replaced by the prospective payment system (PPS), which is based on the quality of care rather than services provided.
Another new initiative implemented by CMS, Bundled Payments for Care Improvement, links “payments for the multiple services beneficiaries receive during an episode of care.” Acute care hospitals, skilled nursing facilities, home health care agencies and inpatient rehabilitation facilities, “enter into payment arrangements that include financial and performance accountability for episodes of care.”
CARF reports that state regulators are also spurring the shift toward performance-based models and criteria by promoting prevention and methods that consider social determinants of heath.
“The future is undoubtedly in favor of providers that can implement strong performance management practices,” according to CARF. Agencies that reorient their practices in this new direction will be well-positioned to achieve and maintain accreditation status.
Contact Accreditation Guru to help put your organization on course to thrive in this brave new world of outcome-based measurement.