Download to read offline
Value Based Care Payment Models - Provider Reimbursement
- 1. Value-based healthcare Is India readyfor a paradigm shift? Click to launch
- 2. Executive summary 3 Whatis value-based care? 5 What are the different value-based care models? 10 Why do we need value-based care? 13 Is India ready to implement value-based healthcare? 17 What would the impact of value-based healthcare on India be? 21 Contents 2 | Value-based healthcare
- 3. 1 Executive summary Traditionally, fromthe payment perspective, the healthcare model has been fee for service, where payment is made on the basis of the number of services provided. This model results in a definite conflict of interest from a patient’s perspective as the focus is on quantity rather than quality of service. However, this model is slowly being replaced by value- based care, where payment is outcome based and providers are rewarded according to the quality of the treatment received. The major aims of value-based care are implementing continuum of care, enhancing patient experience, standardising outcome and cost of care, and treatment delivery through a collaborative chain of activities with measurable outcomes. The different value-based models range from bundled payment to shared risk and shared savings models, depending on the focus of care and financial flexibility. The need for value-based care is realised because of increasing healthcare expenditure, excess healthcare costs attributed to unnecessary and inefficient services along with uncoordinated care. All these factors coupled with increased patient expectations have set the stage for the adoption of value-based healthcare, where the payment for care is tied to clinical outcomes and service quality. Implementation of value-based care would require the building blocks of public financing, resource availability, utilisation of technology and a collaborative ecosystem. In the context of the Indian healthcare system, which largely operates on the fee for service model and has high out-of-pocket expenditure, inadequate infrastructure and technology support, implementing value-based care would require in-depth strategic and financial planning along with transformation of the delivery model. The Government is also expected to play a significant role by implementing enabling policies. Going forward, Ayushman Bharat, with its focus on Government funding and preventive as well as curative care, will lay the foundation for value- based care implementation in India. Once implemented, value-based care will likely result in today’s fragmented care delivery evolving into tomorrow’s circle of care. If implemented as envisaged, in five years, we could look at saving almost 9 lakh lives and reducing healthcare cost by around INR 4,000 billion. 3 | Value-based healthcare
- 4. 4 | Value-basedhealthcare Is India ready to implement value-based care? What would the impact of value-based care on India be? Why do we need value-based care? Key questions we seek answers to What is value-based care? What are its characteristics? What are the different value-based care models?
- 5. 2 What is value-based care? Thereare two major kinds of healthcare models (from a payment perspective): The traditional fee-for-service and the upcoming value-based care model. Fee for service (FFS) Parameters Value-based care Relevance Traditional healthcare model New age healthcare model Reward Quantity-based system in which fees are paid for every service provided Quality-based system in which fees are paid based on the outcome of the treatment Patient centricity Creates a conflict of interest as it provides incentives to caregivers based on a higher number of visits, procedures, tests, treatment, etc., which may not be in line with patient health and wellness. Patients are at the centre of care; providers are incentivised to provide appropriate care and treatment designed to promote health and wellness rather than excessive treatment and profit. Outcome measurement Not done on a regular basis. Also, there are no defined metrics. Reimbursements are usually linked to meeting particular performance criteria. 5 | Value-based healthcare Source: Fakkert, M, Eenennaam, F. V., & Wiersma, V. (2017). Five reasons why value-based healthcare is beneficial. HealthManagement.org, 17(1). Retrieved from https://healthmanagement.org/c/healthmanagement/ issuearticle/five-reasons-why-value-based-healthcare-is-beneficial Industry discussions and PwC analysis
- 6. Value-based healthcare isa payment system that compensates healthcare providers in accordance with the quality of care provided to their patients. Implementing continuum of care Enhancing patient experience Standardising outcome and cost of care Engaging in outcome-based payment Value-based care Major aims to be fulfilled by this system: • A value-based healthcare model prioritises patient-centric care. • It incentivises healthcare providers to keep their patients healthy, which can lower healthcare costs. • Healthcare providers are pushed to provide quality care that improves patient outcomes. 6 | Value-based healthcare Source: Fakkert, M., Eenennaam, F. V., & Wiersma, V. (2017). Five reasons why value-based healthcare is beneficial. HealthManagement.org, 17(1). Retrieved from https://healthmanagement.org/c/healthmanagement/ issuearticle/five-reasons-why-value-based-healthcare-is-beneficial Industry discussions and PwC analysis Prevention of illness and early detection of disease Accurate diagnosis and appropriate treatment to the patient at the right time Fewer complications through minimisation of errors Faster and complete recovery from illness Fewer disabilities and recurrences Clinical implications Value-based healthcare system
- 7. Value-based care aimsto improve patient experience and reduce the cost of care. Aims of value-based care Implementing continuum of care Integrates various aspects of care so that a patient can avail all necessary medical services via appropriate consultation and advice. This will help leverage the best possible treatment options for patients. Enhancing patient experience Treatment is provided in a transparent and cost-efficient manner in order to improve patient experience and increase reimbursement rates. Standardising outcome and cost of care Outcome measurement with the aim of providing quality and patient-centric care at a lower cost leads to higher patient engagement and satisfaction. Engaging in outcome-based payment Shift to outcome-based payment improves the service quality, ensuring optimum resource utilisation. Technology-enabled systems will ensure appropriate data availability and analysis to guide improvement measures. 7 | Value-based healthcare Source: PwC analysis
- 8. Value-based healthcare planningis delivered through a collaborative chain of activities with measurable outcomes. Population study Treatment planning Line of action Designed coordinated care Outcome measurement Paid for value Collaborative activities to deliver value-based healthcare Stakeholders Central authority/Government Central authority/Government and healthcare providers Central authority/Government and healthcare providers Central authority/Government People Planning managers Care team Clinical analyst Executive managers Action Planning and model creation Discussion and data analysis Research on outcome Payment monitoring Activities involved Population study (risk, appropriateness, need) Task allocation and scheduling Outcome analysis Payment calculation Programme targeting Workflow and reporting (shared decision) Record intervention Programme reporting Effective manpower planning (specialist and paramedics) Prioritisation and preparedness Set monitoring/intervention rules Programme optimisation 8 | Value-based healthcare Source: Kaplan, B., & Bower, M. (March 2018). Value-based health care. Harvard Business School. PwC analysis
- 9. At the healthcare-providerlevel, care delivery must lay emphasis on integrated, evidence-based care through shared decision making. Identifying condition Treatment planning Shared decision making Implementing coordinated care Target interventions Outcome measurement Paid for value Population study Treatment planning Line of action Designed coordinated care Outcome measurement Paid for value Patient symptoms Recovery Specialist consultation Possible need for procedure Assess risk and appropriateness Shared decision making Schedule operating room (OR)/treatment Pre- procedure preparedness Procedure Monitoring Focus: Quality of care, wellness and preventive care Value: Improved care quality and outcomes Payment: Based on the outcome The process of care followed at the provider level would promote the aspect of shared decision making which would enhance the line of treatment and also ensure the best possible treatment is provided to the patient at a lower cost. 9 | Value-based healthcare Source: Walsteijn, M. (9 April 2015). Enabling Value Based Health Care. Pathways to Partnerships and Edifecs. PwC analysis
- 10. 3 What are thedifferent value-based payment models? Models Principle Description/details/examples Financial risk to provider Bundled payment • Single collaborated payment for all services in a particular condition such as pregnancy along with childbirth. • Payer knows the payment amount upfront instead of getting the final bill at the end of a treatment course. • Provider benefits from the savings generated by efficiencies within the bundle and the payer would spend less. • Provider faces the potential risk of losing out on cost saving – e.g. if there is any complication. The following bundles were considered in one of the pilot projects in the USA: • Replacement procedures: Knee/hip • Chronic conditions: Diabetes, hypertension and coronary artery disease Medium to high risk Capitation models • In this model, a provider or a group of organisations collects a set payment per patient for specified medical services from the payer. • These payments are usually in the form of a monthly per patient fee. • Single and comprehensive payment for the patient • When the cost of the service provided is below the capped rate, providers would be rewarded. However, providers would be at high risk in case the cost exceeds the capped rate, and this extra cost would have to be borne by them. This could be the case with high-risk and chronic patients. High risk 10 | Value-based healthcare Source: Various publications from Center for Healthcare Quality and Payment Reform Miller, H. D. (2009). From volume to value: Better ways to pay for health care. HealthAffairs, 28(5). Retrieved from https://www.healthaffairs.org/doi/10.1377/hlthaff.28.5.1418 Valence Health. (2013). Models of value-based reimbursement: A Valence Health primer. Retrieved from https://docplayer.net/16514376-Models-of-value-based-reimbursement-a-valence-health-primer.html, Industry discussions and PwC analysis
- 11. Models Principle Description/details/examplesFinancial risk to provider Pay for performance • Financial incentives/disincentives are linked to performance, and a bonus is awarded for exceeding a specific metric or a penalty is imposed for falling short of the threshold. • An example of an incentive linked to achieving the set goal: • A vaccination programme has a goal to vaccinate 70% of its patients by the age of 18 months in accordance with the national guidelines. • If any provider exceeds that goal and vaccinates 80% of the children, it would receive a bonus in addition to the FFS rates. Low to moderate risk Patient-centred medical home • Driven by primary care focusing on building a team of professionals – specialist doctors, medical assistants, technicians, pharmacists (people responsible for coordinating patient care) • Mostly for patients with chronic conditions in order to reduce readmissions and emergency department visits • Providers can negotiate a fee for service rate increase or per member per month over and above the standard FFS payment. Moderate risk 11 | Value-based healthcare Source: Various publications from Center for Healthcare Quality and Payment Reform Miller, H. D. (2009). From volume to value: Better ways to pay for health care. HealthAffairs, 28(5). Retrieved from https://www.healthaffairs.org/doi/10.1377/hlthaff.28.5.1418 Valence Health. (2013). Models of value-based reimbursement: A Valence Health primer. Retrieved from https://docplayer.net/16514376-Models-of-value-based-reimbursement-a-valence-health-primer.html, Industry discussions and PwC analysis
- 12. Models Principle Description/details/examplesFinancial risk to provider Shared risk • In this model, providers have the incentive of sharing cost savings and the disincentive of sharing the excess costs of care delivery. • This system is based on a pre-decided budget with a payer, and calls for the provider to cover a portion of costs if savings targets are not achieved. • In this model, the payer needs to prepare a shared risk structure that the provider would be inclined to accept. • The provider can limit its risk by appointing a third-party insurer and paying them a fixed fee for accepting all financial risk beyond a certain point. High risk Shared savings • The payer and provider enter into an agreement that includes patient attribution, service provision and estimated medical costs. • Providers would submit bills and claims as in the routine FFS model. • Bills are submitted as under the FFS model, post which analysis and review would be done by the payer and provider to identify the savings generated, if any. If the bills are below the target set by the payer, the provider is eligible for a certain share of the savings. • In case the bill is above the set target, no penalty is levied on the provider. • One downside is that providers that already work in a cost-effective manner would be less inclined towards adopting this model. Moderate risk 12 | Value-based healthcare Source: Various publications from Center for Healthcare Quality and Payment Reform Miller, H. D. (2009). From volume to value: Better ways to pay for health care. HealthAffairs, 28(5). Retrieved from https://www.healthaffairs.org/doi/10.1377/hlthaff.28.5.1418 Valence Health. (2013). Models of value-based reimbursement: A Valence Health primer. Retrieved from https://docplayer.net/16514376-Models-of-value-based-reimbursement-a-valence-health-primer.html, Industry discussions and PwC analysis
- 13. 4 Why do weneed value-based care? Healthcare expenditure as a percentage of GDP has seen a steady rise, putting pressure on health systems. Even as healthcare expenditure is on the rise, healthcare delivery costs remain a major concern. Around 17 countries in the graph below are spending close to 10% or more on healthcare only. USA 1 11 21 Switzerland Sweden France Germany Japan Netherlands Austria Denmark Canada Belgium Ireland New Zealand Finland UK Spain Italy Greece Czech Rep Mexico Russia China India Healthcare expenditure as a percentage of GDP over 15 years1 2001-2005 2006-2010 2011-2015 Increase in expenditure 13 | Value-based healthcare 1 OECD data on healthcare spending
- 14. Excess healthcare cost Preventionopportunities missed 7% 10% 14% 17% 25% Unnecessary services 27% Source of excess healthcare costs in USD billion in 20092 Fraud Surplus admin costs Exorbitant pricing Inefficient services In 2009, the total amount of unnecessary healthcare costs in the USA was estimated to be USD 750–765 billion – that is, around one-third of the total healthcare spend. 14 | Value-based healthcare 2 Institute of Medicine. 2013. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: The National Academies Press. https://doi.org/10.17226/13444
- 15. Making the shiftfrom the current system of fragmented provider-based care to coordinated team-based care poses a challenge to the adoption of value-based healthcare. Integration of coordinated care with a focus on patient centricity would enable an integrated healthcare set-up that leverages value-based care delivery. Uncoordinated care Lack of health coverage Need for patient centricity Between 2011 and 2014, US citizens had a 17% readmission rate for pneumonia and heart attacks.3 Medical errors are the third leading cause of death in the USA after heart disease and cancer, with around 250,000 deaths in 2018.4 There is substantial evidence that a major percentage of healthcare spending is squandered on avoidable medical complications or redundant treatments. Developing countries face a lack of health coverage, which is directly impacting the accessibility of healthcare services to the population. As per the IRDAI, only 24% of the Indian population is covered under public or private health coverage.5 Value-based care would be an enabler for improving the current scenario. Value-based healthcare has proved to be a cost-effective as well as patient-centric delivery system where payment is based on outcome and quality. 15 | Value-based healthcare 3. CMS research 4. Sipherd, R. (22 Feb 218). The third-leading cause of death in US most doctors don’t want you to know about. Retrieved from https://www.cnbc.com/2018/02/22/medical- errors-third-leading-cause-of-death-in-america.html 5. National Health Profile 2017, PwC analysis
- 16. Increasing pressures ofhealthcare spending, care costs and patient expectations have set the stage for the adoption of value-based healthcare where the payment for care is tied to clinical outcomes and service quality. • In the case of the above countries, 90–100% of their population is covered under public or private insurance. • The cost per outcome point value shows the actual expenditure per population: − − For example, the USA spends USD 107.8 per head, while 90% of the population is covered under insurance. − − At the same time, South Korea spends only USD 20.2 USD per head, while 100% of the population has insurance cover. • It is evident that greater health coverage can be achieved even at a lower cost. Value-based healthcare can lower healthcare spending. Healthcare spending is not always proportional to health outcomes. The cost per outcome point may vary based on the efficient allocation and utilisation of resources in delivering optimum healthcare services. Cost per outcome point = Health outcome index/ Total healthcare spending Health outcome index – composite outcome of disability-adjusted life years (DALYs), health-adjusted life expectancy (HALE), average life expectancy at age 60 and adult mortality rates Healthcare outcome 47.9 65.6 29 55.8 53.8 62.1 20.2 67.6 41.3 107.8 98.4 94.1 93.8 92.5 92.2 91.6 90.8 90.3 89 85.5 Japan Australia Spain Sweden France Canada South Korea Netherland United Kingdom United States Healthcare spending vs cost per outcome6 Cost per outcome point Health outcome index 16 | Value-based healthcare 6. The Economist Intelligence Unit. (2014). Health outcomes and cost: A 166-country comparison. Retrieved from https://www.eiu.com/public/topical_report.aspx?campaignid=Healthoutcome2014 Spending is not always proportional to the care delivered. It can be observed that even though the USA has the highest cost per outcome point, it has a lower health outcome index compared to its peers.
- 17. 5 Is India readyto implement value- based healthcare? The major building blocks for implementing value-based care include public financing, resource availability, utilisation of technology and a collaborative ecosystem. Willingness to align with a new age system Technology and data-driven performance Cooperation and shared responsibility Increased healthcare financing from the Government Availability of adequate infrastructure and resources Building blocks for value-based care 17 | Value-based healthcare
- 18. The FFS paymentsystem rewards doctors based on the number of procedures performed, without much focus on the clinical outcome. 1 Absence of essential healthcare infrastructure and inadequate resources are some of the major challenges in the overall healthcare scenario. 3 4 Lack of IT integration and limited accessibility of electronic medical records (EMRs). The central data repository for predictive analytics and treatment planning has a long way to go. 5 Different stakeholders are working in silos with minimal coordination. 2 Out-of-pocket expenditure (OOPE) as a percentage of overall health expenses in India is significantly higher compared to the global average. OOPE as percentage of overall healthcare expenditure in 2016 64.6% 35.9% 11.1% 18.6% India China USA World average Healthcare workforce per 1,000 population 0.7 doctors 1.3 nurses The Indian healthcare system, which largely operates on the FFS model, has high OOPE expenditure and inadequate infrastructure and technology support. 18 | Value-based healthcare Source: World Bank data (2016), industry discussions, PwC analysis
- 19. Alignment with value-basedcare would require strategic and financial planning along with transformation of the delivery model; the Government also plays a significant role in implementing enabling policies. Strategic vision The volume to value shift requires strategic alignment with new economic and business relationships on the horizon. 1 Financial preparation Today’s FFS payment model would soon be converted to an outcome-based payment model, but the transition would be gradual and providers need to have a plan in place. 2 Delivery model transformation Integrated care is the way forward and collaboration among stakeholders is a prerequisite. Development of the right mindset, utilisation of the necessary tools and capability development are required. 3 Resource optimisation An optimum blend of skill, talent and people would facilitate the shift towards value-based care. Engagement with clinicians, who are going to be co-owners of outcome-based treatment, is a critical cornerstone. 4 Enabling policies Nations moving towards value-based care require an ecosystem of enabling policies and supportive institutions that will help align all the stakeholders from provider to patient. The Government needs to play a major role in establishing the policy agenda. 5 19 | Value-based healthcare Source: Industry discussions, PwC analysis
- 20. Ayushman Bharat, withits focus on Government funding and preventive as well as curative care, will lay the foundation for value-based care implementation in India. Features of Ayushman Bharat 500 million beneficiaries (~100 million households to be covered) 1,350 surgical packages covered under the scheme Proposed Aadhaar linkage Family floater cap of INR 500,000 Premium to be borne 60:40 by the Centre and state Purchasing to be done by the National Health Agency and State Health Agency Both public and private hospitals to be empanelled The payment mechanism of Ayushman Bharat needs to be adapted in accordance with the gradual shift from volume- to value-based care. Wellness Outpatient care Post-operative care/ rehabilitation Investigations Hospitalisation Wellness Preventive care, primary care, immediate care 1 Outpatient care Specialist care, emergency care, ancillary care 2 Investigations Diagnostics 3 Hospitalisation Inpatient care 4 Post-operative care/ rehabilitation Long-term care, skilled nursing, end-of-life care 5 20 | Value-based healthcare Source: India Today Web Desk. (25 Sept 2018). All about PMJAY-Ayushman Bharat, the national health mission. Retrieved from https://www.indiatoday.in/india/story/all-about- pmjay-ayushman-bharat-the-national-health-mission-1348387-2018-09-25 ET Online. (31 Dec 2018). Ayushman Bharat health insurance: Who all it covers. Retrieved from https://economictimes.indiatimes.com/wealth/insure/ayushman-bharat-how-to- check-entitlement-and-eligibility/articleshow/65422257.cms?from=mdr, Industry discussions and PwC analysis Continuum of care
- 21. 6 What would the impactof value-based healthcare on India be? Today Indian healthcare Future Quantity Reward Quality Fragmented (in silos) Care offered Cycle of care Subject of care Patient Leads care provision Less transparent Transparency Transparency Vendors Stakeholder Partners Revenue generation Business aim Expense management Provider dependant Treatment Evidence based The current system of healthcare is in ‘silos’, which makes it difficult to provide the best possible outcome at the lowest possible cost. The fragmented system causes duplication of work and increases the cost while also reducing patient satisfaction. Value-based healthcare will bring together all modalities of care delivery to create a well-coordinated ‘continuum of care’. Once implemented, value-based care will likely result in today’s fragmented care delivery evolving into tomorrow’s circle of care. The Future: Circle of value- based healthcare 21 | Value-based healthcare Source: ECG Management Consultants. (Feb 2019). Transformational drivers in the health system of the future. Retrieved from https://www.ecgmc.com/ thought-leadership/whitepapers/transformational-drivers-in-the-health-system-of-the-future Industry discussions and PwC analysis Virtual health Pharmacy Diagnostics Home healthcare Payer Hospital
- 22. With the rightimplementation, value-based care could significantly reduce healthcare cost and improve clinical outcomes in India. 2019 INR 2,272 billion (USD 32 billion) 8.7 lakhs 2024 9.1 lakhs INR 4,004 billion (USD 57 biilion) Healthcare cost saving Lives saved 22 | Value-based healthcare Source: Industry discussions, PwC analysis
- 23. The success ofvalue-based healthcare can be evaluated at all levels using measurable indicators for assessing quality of care outcomes and cost parameters. 8 2 6 4 3 7 1 5 Clinical quality indicators Percentage of population with health coverage Out-of-pocket expenditure Cost per outcome point per head Healthcare spending – percentage of GDP Accessibility of clinical outcomes Compliance with evidence- based clinical guidelines Existence of integrated EMR Monitoring the KPIs below would help in analysing the adoption rate by healthcare providers. 23 | Value-based healthcare Illustrative KPIs
- 24. About PwC’s Healthcarepractice Acknowledgements Healthcare team Dr. Preet Matani Ashish Rampuria Varun Karwa Dr. Kuntal Mukherjee Dhriti Mitra Marketing and Communications team Dion D’Souza Pallavi Dhingra 24 | Value-based healthcare PwC India’s Healthcare team offers advisory services in the healthcare sector covering multiple domains such as strategy, business planning, market scan, commercial due diligence, feasibility study, operations improvement, cost reduction, health IT, digital and technology, internal audit and PPPs. The Healthcare Advisory team of 25 members combines over 40 years of operational experience in setting up and managing hospitals, and over 60 years of healthcare consulting experience. This enables the team to deliver granular strategy and market and operational insights of the highest quality. The team works with leading healthcare providers, medical technology companies, central and state governments, diagnostic players, insurance companies and private equity players on projects both in India and overseas. Contact us: Dr. Rana Mehta Partner and Leader, Healthcare PwC India D: +91 124 6266710 | M: +91 9910511577 [email protected]
- 25. At PwC, ourpurpose is to build trust in society and solve important problems. We’re a network of firms in 158 countries with over 250,000 people who are committed to delivering quality in assurance, advisory and tax services. Find out more and tell us what matters to you by visiting us at www.pwc.com. In India, PwC has offices in these cities: Ahmedabad, Bengaluru, Bhopal, Chennai, Delhi NCR, Hyderabad, Kolkata, Mumbai, Pune and Raipur. For more information about PwC India’s service offerings, visit www.pwc.in PwC refers to the PwC network and/or one or more of its member firms, each of which is a separate legal entity. Please see www.pwc.com/structure for further details. © 2019 PwC. All rights reserved About PwC Data Classification: DC0 This document does not constitute professional advice. The information in this document has been obtained or derived from sources believed by PricewaterhouseCoopers Private Limited (PwCPL) to be reliable but PwCPL does not represent that this information is accurate or complete. Any opinions or estimates contained in this document represent the judgment of PwCPL at this time and are subject to change without notice. Readers of this publication are advised to seek their own professional advice before taking any course of action or decision, for which they are entirely responsible, based on the contents of this publication. PwCPL neither accepts or assumes any responsibility or liability to any reader of this publication in respect of the information contained within it or for any decisions readers may take or decide not to or fail to take. © 2019 PricewaterhouseCoopers Private Limited. All rights reserved. In this document, “PwC” refers to PricewaterhouseCoopers Private Limited (a limited liability company in India having Corporate Identity Number or CIN : U74140WB1983PTC036093), which is a member firm of PricewaterhouseCoopers International Limited (PwCIL), each member firm of which is a separate legal entity. PD/September 2019-M&C 458