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A Look at Health Care's Reimbursement Future at ORX

Attendees learned about the triple aim of care: quality, cost and patient satisfaction.

Published: October 13, 2017

LOOKING AHEAD Dr. Zeev Kain says improving the quality of care will be as important as controlling costs.

The future of facility reimbursement will focus on the value, not the volume, of surgical care, according to Zeev Kain, MD, MBA, FAAP, president of the American College of Perioperative Medicine and chair of the department of anesthesiology and perioperative medicine at the University of California School of Medicine in Irvine, Calif. He told OR Excellence attendees this week that controlling costs, improving the quality of care and enhancing the patient experience will drive revenues in the future as value-based care takes hold.

"But value-based care is not simply an economic model," said Dr. Kane. "What's the value to patients? That's the true definition of value-based care."

Dr. Kain said it's impossible to know exactly where health care and healthcare reimbursement are headed, but he offered some educated predictions:

  • Bundled payment initiatives are moving forward and commercial bundles have arrived. In 2016, 45% of Aetna's spending was done through some form of value-based care. The insurer wants that percentage to reach 75% by 2020.
  • CMS is proposing to remove total knee replacements from the inpatient-only payment list, in part because the cost of total joint replacement in the ASC setting is approximately 50% less than in the inpatient setting.
  • Traditional roles have vanished. Hospitals now partner with insurance companies and take more risks, third-party payers are buying physician groups and patients are paying cash in pre-agreed networks with lower prices.
  • The move to system-based care will continue. Dr. Kain believes a growing number of ASCs will be part of healthcare systems in the future, whether that's under a hospital's umbrella or part of an independent conglomerate.
  • There's more opportunity for ASCs and hospitals to work together. Dr. Kain said healthcare systems will work best when there is equilibrium, collaboration and clinical integration.
  • The outpatient migration continues. Dr. Kane said the ratio of inpatient procedures will decrease 2% to 4% between 2017 and 2027, while the rate of outpatient procedures will increase between 15% and 23% during the same period.
  • The fee-for-service payment model is not coming back under the presidency of Donald Trump, according to Dr. Kain. "The candidates in line to replace the former Secretary of Health and Human Services Tom Price are more in favor of value-based care than he ever was," explained Dr. Kain. "In addition, there are too many drivers of value-based care already in place. CMS, commercial payers, accountable care organizations and patients are all demanding value in health care."

Dr. Kain also discussed skyrocketing healthcare costs. Although the cost of care is increasing across the world, U.S. health systems are paying approximately double what the rest of the world is spending. The annual growth in healthcare expenditures was 3.6% in 2013 and increased to 5.8% in 2015.

Healthcare leaders who want to lower the cost of care must work with teams who are expert in managing operational factors, clinical considerations and the patient experience, said Dr. Kain.

"When you are trying to transition from fee-for-service to value-based care, don't go home and do it yourself," Dr. Kain told the audience. "Build a team involving all aspects of patient care and facility management, and make sure every member of that team does their part to build a sustainable model."

Daniel Cook


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