Updated: Jun 17
A closer look into the significance of Value-based Reimbursement, Physician Documentation, and Key Performance Indicators (KPI) in 2021
Originally Published by Illumination Curated on Medium
Photo by Sigmund on Unsplash
For decades the realm of healthcare has been moving from a patient-centered personalized medical service to a corporate-based population health model. Not too many years ago, the healthcare administrators were contemplating a system that is meant to offer a precision-based healthcare delivery model; three issues exist, which would fail some parties if unresolved during the delivery of care. In this case, that is the physician and patient.
In 2021 healthcare will continue fast-forwarding, emphasizing three elements of modern medical practice: value-based reimbursement, physician documentation, and key performance indicators. Compliance with the latter triad of the 2021 healthcare elements is a deal Breaker to the sovereignty of patients and physicians.
In January 2015, the Department of Health and Human Services (HHS), for the first time, announced that it was switching fee-for-service Medicare payments to a value-based reimbursement model and intended to do so by the end of 2018. HHS did so by unveiling the scheme called the “MACRA” framework that primarily focused on substitute payment models for quality care improvements, which led many providers to start investigating the switch to value-based care.
The value-based reimbursement unraveled fast and robust so that it goes the medical community off guard. Even today, the transition to a merit-based payment system is an intricate task for individual clinicians and many organizations. Because value-based reimbursement models function the best, require robust data analytics capabilities, population health management programs, and successfully use state-of-the-art information technologies for documentation and reporting such as Electronic Health Record (EHR).
It is not as complex to roll out a system that would operate under a value-based approach to agree upon the terms of the value of the care and on whose terms. That is precisely why, despite overwhelming efforts towards implementing the new reimbursement model and technological breakthrough. Physicians are burning out, and patients are less satisfied.
Undoubtedly, in 2021 physicians need to accept that they need to arm themselves with more robust tools and sleeker strategies to stay in the game. However, since there is a lack of consensus as to what entails a good value of service and transparency throughout the process, it is clear why most physicians today are still struggling to maintain their sovereignty.
Value is somewhat driven by the quality of service and modified by its supply and demand. Quality, particularly in the healthcare stage, is the derivative of physicians’ objective determination and patients’ subjective perception at a particular time and location. Thus, the latter demands a “Personalized healthcare” setting.
It is quite pertinent that the HHS criteria for quality service are more than partially based on a set of arbitrary social determinants of health and disease. However, that may bring quality and value to the table for patient care that is far from a deal that is as personal as a doctor-patient encounter. But, irrespective of what the measure of quality and value are amidst value-based reimbursement schemes still, physicians have no choice but to comply if they genuinely want to stay in practice. Because whatever is being dictated has already become the standard of medical care. Thus, the prevailing merit-based reimbursement system is a one-size-fits-all medical practice scheme. It embraces a structure where a patient at one end of a socioeconomic zone will have the same treatment for the same form of disease s on the other end of the same community. Under personalized healthcare, every individual deserves to receive their custom treatment modality, embracing their own set of quality criteria and values. Therefore, the value-based reimbursement criteria will adjust to the specific encounter.
From papyrus to the electronic health records (EHR): and patient-related data in clinical settings with rapidly accelerating adoption history of the development of medical records in the West suggest sermons applicable to the current evolution.
The early reported significant transition in the evolution of the clinical medical record happened in antiquity, with written case history reports for didactic purposes. From classical and Hellenistic models earlier than physicians in the West, medieval Islamic physicians continued developing case histories for didactic use. A forerunner of modern medical records first appeared in Paris and Berlin by the early 19th century. The development of the clinical form in America was pioneered in the 19th century in major teaching hospitals. However, some people did not develop a valuable clinical medical record for direct patient care in hospitals, and they failed to establish ambulatory settings until the 20th-century.
Over century-old physicians, documentation has evolved significantly both for clinical encounter documentation, didactic and proof of clinical decision making to prevent legal obstacles. Advances in big data, artificial intelligence (AI), and value-based reimbursement have prompted information tech industries to support healthcare administrators to take the physician documentation requirements to a new level.
The new standards demand physicians collect and submit quality-specific data such as Social determinants of health and disease as part of the scheme that sets the standards for physician reimbursement protocol. The latter refers to poverty, unequal access to healthcare, lack of education, stigma, and racism are underlying contributing factors of health inequities.
Like other performance-based accountability, social factors have their particular Key performance indicators (KPI) or the critical (essential) indicators of progress toward an intended result. When applied to the digital realm, KPI’s are represented as a set of data that provide information about other data, also called Metadata.
Implementing KPIs and Metadata into physician practice metaphorically opens another can of worms in an already struggling healthcare system as it places the burden on already burnt-out physicians. Adds more administrative demand. Some are planning to automate the compliance with collecting and processing social determinants and other needed Metadata through implementing liberal Artificial intelligence and data mining practices. Then again, unfortunately, there is a significant transparency lack on most artificial intelligence algorithms. That makes the patient and physician’s data unsafe and clinical decision-making practices biased.
The Monopoly of the Key Performance Indicators (KPI)
Key performance indicators are a set of pre-ordained parameters, thus are subject to manipulation and meddling unless we establish proper transparency on how it is designed, selected, and applied. It must be customized for individual needs and updated often. But the monopoly of metadata and KPI standards will benefit some and hurt others. A few with alternate intentions like fiscal gain can easily manipulate a physician to practice a certain way because a bureaucrat or a technocrat feels a certain way. And that is easier done if there is no consensus about the actual quality, and what a value means to a given person. But ironically, the most prevailing KPIs are the product of importance set by bureaucrats.
Personal determinants of Health and Disease are essential to better KPI
KPI metrics focus attention on what is necessary. Balanced metrics of primary healthcare inform purpose and aspiration as well as performance. The objective of primary healthcare is to improve the health of people and populations within the context of their community.
The purpose of KPI metrics is to point to what is essential for individuals that may be neglected amidst pressing day-to-day concerns. They allow us to consider various options along the path of decision-making. That is what is being done well for every patient, what might be better left undone, what needs to be changed, and what is essential and therefore needs to stay intact without deviation from the standard of care set by doctor-patient interaction.
Metrics in healthcare assess accomplishment, including processes and their outcomes. They continuously inform reflection on the purpose and facilitate aspirational dialogue between individuals that lead to lasting improvement. Correlating KPI to compensation may increase the quality of narrowly discerned care in the short term, but risks coerced consequences in the longer term. Although it works in response to the social determinants of health, it is more relevant when applied to individual cases.
That is precisely why today, healthcare is in the midst of a paradigm transformation that attempts to merge the benefits of personalized care.
Acknowledging the By Whom and how of key Performance Indicators (KPI) is critical for delivering Personalized Healthcare
The hidden agenda of value-based reimbursement and manipulation of clinicians is a primary concern amid the increasing takeover of the healthcare system by the tech industry and the administration in the hands of non-clinicians. Recognizing the significance of KPIs is one thing, but their utility in the clinical stage is another ball game.
It is essential to recognize that the KPI is simply a target measure where such measure requires to be about the point of comparison. For example, a KPI may point to ten minutes of consultation time spent with a patient concerning smoking cessation. Or it may allow a total of twenty minutes for a physician to perform a complete medical evaluation within which the physician must spend ten minutes of smoking cessation consultation to receive full allowable reimbursement from the insurance company.
In conjunction with lack of transparency regarding the selection of key performance indicators, the prime intention of the set measures can be obscure from the medical community, thus driving the physician performance in any direction they may intend.