Navigating the Shift to Value-based Reimbursements

MINNEAPOLIS - Say good-bye to the straightforward model of volume-based reimbursement. A value-based model is becoming the new reality, and imaging facilities still need to figure out how to make that profitable. 

“At the end of the day, the real change here is there’s not necessarily going to be a direct relationship between what you collect and the number of exams you do,” said consultant David Smith, BAA, MPA, FACMPE, speaking this week at the AHRA 2013 annual meeting. “You have to focus on where your organization can excel in terms of value.”

The industry is just on the cusp of this transformation to an emphasis on quality, Smith said, and the contracts involved in this new model are still being written. That’s why it’s imperative that radiology organizations work with patients, third-party payers and other business partners to negotiate agreements and drive the conversation regarding what “value” means and how to quantify it.

“The challenge is going to be if you have 15 different payers in your market and 15 different models, and they each have 10 different things that they’re measuring,” Smith said. “You want those 10 to be fairly consistent across all those payers, or else it’s just going to be totally unmanageable.”

Smith said the kind of metrics that drive value differ somewhat depending on the kind of value-based model being used. Various models include fee-for-service (FFS) reimbursement, tiered FFS systems, purely value metrics, or FFS combined with bonuses if certain goals are met.  

Consider the value of maximizing patient access, for example. Smith said that strategy has a high reward for traditional fee-for-service models, but for the other models it would depend on how the incentives are set and how the model is set up.

“That’s something you want to work on in the front end in terms of negotiation to drive the metrics in your favor to make them as compatible as possible with the business you already have,” he said.

Still, some priorities are universal no matter what model is in play, he said, such as price transparency. Price information is becoming more easily accessible on the Internet, and high deductible healthcare plans give consumers a bigger incentive to go digging for those numbers.  

“Patients have more skin in the game,” Smith said. “They’re going to want to know in advance what something is going to cost. … You’ve got to look at it more like having your goods on a shelf in a store.”

Other factors of value in imaging include patient and ordering provider satisfaction, service differentiation and appropriateness.

“There’s a real opportunity there in terms of making sure the right study gets done the first time,” Smith said. “And we’re not just doing things by rote automatically because it increases our volume.”