1. Pierotti, Danielle PhD, RN, CENP, CHPN

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As home care moves away from the fee-for-service (FFS) model, toward a value-based payment (VBP) model, it is critical that the clinical and financial teams learn to speak a shared language. We must share a common understanding of economic, clinical, measurement, and performance improvement terms and applications, starting with the idea of "value."


Value, in the economic sense, is defined as monetary worth. Goods and services have a price tag. Healthcare is no different. As consumers, we make choices everyday about how we spend our dollar. How we spend our dollars shows how we value the good or service. We can buy luxury items at one price point or a comparable item at a discounted price. The difference between the luxury and discount versions of the same item is measured by the quality of the item. Our decision to pay for luxury or discount is primarily based how we value the item.


Clinical care is a service consumers purchase. Consumers purchase clinical services to meet their needs. In the healthcare industry, the clinician's expert knowledge is the primary service purchased. Goods, like medications or equipment, are purchased as a result of the expert's direction. Expert knowledge transforms into money as a function of time. Physicians, advanced practice nurses, and therapists of all varieties are experienced in billing for their time. Most nurses are not. In hospitals and other facility-based care, nursing care and nurses are considered part of the "bed" cost. In home care, the payment for "skilled nursing" is a central component of the current FFS reimbursement model. However, the calculations that connect the nurses' time to the bill are typically invisible to the nurse. The calculations connecting nurse to bill are the work of the financial team who rarely has direct interaction with the direct care providers. As we move away from this model, the decision to purchase home care will increasingly be made on the value of the service. To be successful in VBP models, nurses must join other clinicians and become active partners in managing the connection between their expertise and billing.


The decision to purchase healthcare and at what price point is very complicated. In other industries, value is largely defined by the consumer of the product, who is typically also the payer, evaluating the cost and quality together. In healthcare, the consumer of care and the payer are normally separated by many layers. Consumers of care pay indirectly through insurance premiums or employment taxes long before care is used; or through copays and deductibles often billed months after the care was received. True payers of care are typically government programs or insurance companies without direct connection to the person receiving care. This separation of consumer and payer, and the time between service use and bill makes defining and describing value in healthcare difficult and disjointed. Further, information about the cost and quality of the service is hard to attain and kept separate, leaving the consumer unable to evaluate the value of their care.


The VBP model provides opportunities to minimize this gap. Payers are trying to understand the value of healthcare by focusing on the patient's outcomes. They are investing in defining the value of care through measurement and using it to make payment decisions. To achieve success in this model, consistent communication between clinical and financial experts must occur. Clinicians must understand how their work is measured. Financial leaders need to understand the financial impact of the clinical work. Together, everyone must share definitions of high-quality care. Highlighting the importance of the marriage of financial and clinical experts, this column will explore key components of this overlap, by highlighting individual measures, operational issues of delivering care and the possible financial impacts, as a starting point for communication over the following months.