September 21, 2015: Two years ago, during a discussion that followed a presentation I had given to a meeting of nurse educators, clinicians and administrators, a nurse manager took the microphone and proclaimed, “All this talk about value – value based purchasing, value based payment, value-based care delivery, value-based this, value-based that – I wonder if it’s not just another fad and nothing is really going to change.  So tell me, should I take all this value stuff seriously?”

I rattled off something that seemed convincing, but the question lingered in my mind and caused me to wonder how pervasively other nurses hold the same suspicion.  Consequently, I began to include material in my presentations about value and the implications for clinicians and administrators.  I listened closely to people’s reaction to gauge whether I had convinced anyone that the search for value is not a fad.  Fundamentally, I argued that the switch to value-based payment systems is likely to be the most important goal of health reform. More over, I declared that, if we’re lucky, the search for value will stimulate the development of the new “value-conscious” nursing workforce.  Let me briefly explain.

Value-Based Payment and Health Reform

Overall, the goals of health reform are fairly straightforward:

  1. Change health care delivery systems to improve coordination, quality, efficiency and accountability (ACOs, medical care homes, etc)
  2. Increase emphasis on prevention and education to decrease future inappropriate and avoidable demand and to promote better health outcomes
  3. Expand access to care through insurance reforms
  4. Change payment system to strip away volume-based utilization incentives in the fee-for-service system in favor of more efficient, value-driven care

The last goal may be the most important, if controversial, because adopting a value-based payment approach is necessary to align the behavior of people and organizations to accomplish the first three health goals.

Policy makers understand this.  Consider the announcement last March by HSS Secretary Sylvia Burwell, who declared that 80% of Medicare fee for service payments will be tied to quality/value in 2016.  This figure would rise to 90% of payments in 2018.  The Secretary further proclaimed that 30% of Medicare payments would be made to alternative delivery systems in 2016, increasing to 50% in 2018.

As if this wasn’t a strong enough message, not long after this announcement Congress changed the way physicians will be paid by Medicare.  The linkage to the SGR will be replaced with a payment system (also covering nurse practitioners and physician assistants) that will be based on a clinician’s quality of care, use of resources, meaningful use of EHRs, and clinical practice improvement.  Additionally, bonuses and penalties will be linked to performance scores and higher fees will be available to clinicians who work in alternative payment organizations.

Doesn’t sound much like a fad to me.

Implications for Nurses.

The impact of the shift to value based payment won’t be limited to physicians alone and nurses should anticipate how value-based payment methodologies will directly affect their practice.  To prepare for a new value based world, nurses should be sure they know what clinical outcomes are vitally important to the organization that employs them.  Nurses won’t be able to affect the achievement of some of the outcomes, but there will be other outcomes that nurses can influence substantially – for example, decreasing re-admissions, reducing mortality, preventing infections, decreasing errors, avoiding complications, etc.  For these nurse-sensitive outcomes, nurses can create added value by increasing the quantity (or the quality) of the outcomes, decreasing the costs of producing the outcomes, or do both – improve the outcomes and decrease their costs simultaneously.

Not only will focusing on creating value help align nurses’ activities closer to the core interests of the organization, but nurses will become a partner in helping organizations find their way in a rapidly evolving health care delivery system.

Fall 2015 Webinar Series

The Center is delighted to organize the fall webinar series on the shift to value and its implications to the nursing workforce to further explore some of these issues I’ve raised. We’re fortunate to have the opportunity to bring you thought provoking presentations by individuals who have been thinking about value and understanding what it means for the future of the nursing, and in fact, the larger health care workforce.

We will begin the series on Wednesday September 23rd at 2pm EST with Richard Lindrooth, a Professor and a co-Director of the Health Service Research Doctoral Program in University of Colorado’s Colorado School of Public Health. This webinar outlines the definition of value in health care and reviews the evidence on how nurses can and have improved value. We highlight and summarize evidence related to increasing value, including interventions that improve quality and show promise for increasing value.

On Tuesday October 6th at 2pm EST, a related webinar, led by Olga Yakusheva, Associate Professor of Nursing at the University of Michigan, will use the same definition of value but will focus on how policies and incentives can either help of hinder value creation.  Increasing health care value has increasingly become a central objective of payment policies, insurance design and purchasing, and patient and provider decision-making.  For example, the word “value” appeared in the title of seven sections of the Affordable Care Act (ACA), and earlier this year CMS set a goal of 50% reimbursement being “value-based”. This webinar will describe value-based purchasing initiatives and how they will influence the value of nursing care.  We highlight evidence on where policy has been successful at increasing value and areas where there is importance for further improvement.

We are in the process of confirming the rest of the webinar presentation dates and speakers and will keep you posted as the event details are confirmed. We look forward to “seeing” you at our events!

Peter Buerhaus and Christy Friedman