Value-based care (VBC) has turned the industry’s focus toward quality of care rather than the traditional fee-for-service model’s focus on volume. Clinical settings are often at the forefront of the VBC conversation, but there are many opportunities to apply VBC to other areas of healthcare.
Personal Care Services (PCS) is an area with tremendous potential for Value-Based Contracting expansion. Regular engagement with members and patients allows for organic influence on closing care gaps, and the propensity of high-cost events like hospitalization creates ample opportunity for shared savings.
Value-Based Care – Slow Progress, But in the Right Direction
Since its introduction in 2006, VBC has slowly transformed how care is delivered and paid for. Historical fee-for-service payment models have rewarded high volume and high acuity care – complex surgeries, expensive drugs, and more. VBC, instead, is designed to reward value – including prevention and detection, earlier intervention, improved health outcomes, and better patient experiences. The continuum of VBC extends from incentives for adherence to evidence-based standards and closing gaps in care, to shared savings and ultimately, shared risk. Effective models will lower the total cost of care over time, achieving the triple aim.
Despite great enthusiasm for the promise of VBC models, the transition has been slow. Payors have been disciplined, reviewing data and healthcare economics models to identify opportunities for prioritization and to establish financially sustainable models. Providers have also been cautious, developing new approaches to their workflow and assessing their ability to impact outcomes at a sustainable cost.
The measured introduction of VBC has tended to emphasize populations with high acuity (i.e. Medicare and Medicare Advantage), and specialties with either broad influence (i.e. primary care) or concentrated spend (i.e. orthopedics, oncology, etc.).
We are starting to see the impact of meaningful VBC models. In a Humana study, there were 30.1% fewer in-patient admissions for VBC patients compared to original Medicare beneficiaries in 2022. Yet VBC in home care and personal care services is lagging. CMS is expanding on its initial attempts in traditional Medicare, but Medicaid, which covers a significant portion of personal care services in the country, is just beginning.
Personal Care Services in the Home – The Next Frontier
Nationally, more than 4 million people receive personal care services through state waivers or Medicaid, and that number has been rapidly growing in recent years. In-home caregiving is a favorable alternative to institutionalized care, with more adults opting to stay in their homes as they age, and payers struggling with the cost of hospitalization and post-acute transitional facilities, among other institutions. When patients can be transitioned from high-cost settings to their homes, payers and patients save money and patients receive care in the setting they prefer, freeing up hospital beds in an overwhelmed healthcare system to better meet the needs of communities.
PCS is a natural fit for VBC expansion given that these services are embedded throughout members’ and patients’ daily lives at home. Caregivers are uniquely positioned to overcome industry-wide obstacles and act on opportunities that will improve patient outcomes. One of the greatest challenges payers and providers face today is engagement – capturing a member or patient’s attention and getting them to take a recommended action, such as scheduling an annual wellness exam or preventative screening. Personal caregivers can play a vital role in closing these care gaps by scheduling and accompanying members to medical appointments.
Additionally, increasing medication adherence to improve outcomes and lower the total cost of care for members with certain chronic conditions is another great opportunity. While non-clinical personal care assistants cannot prescribe or administer medication, they can provide reminders and monitor a member’s prescription regimen.
Individuals who qualify for at-home PCS have a much higher rate of hospitalization than the general population, and payors and providers could partner to create home care protocols to reduce the hospitalization and readmission rate of this population.
As adults continue to age in place, PCS represents the next frontier for VBC. Personal caregivers’ regular engagement with members positions them as essential to closing care gaps and decreasing the number of hospitalizations. By incorporating a VBC model into PCS, patients can experience improved health outcomes and shared savings.
Chelsey Berstler
Chelsey Berstler serves as the Executive Vice President of Personal Care Services of Modivcare, a technology-enabled healthcare services company that provides a platform of integrated supportive care solutions focused on improving health outcome. With a robust track record as a proven executive, Ms. Berstler brings extensive experience from both U.S. and global markets in managed care, government programs, healthcare delivery, and pharmacy care services. Chelsey is renowned for establishing clear, impactful objectives, and achieving aggressive targets in high-value, highly visible environments, demonstrating adeptness in process discipline, influential partnerships, and navigating complex stakeholder relationships.
Prior to joining Modivcare, Ms. Berstler was Chief Commercial Officer at NationsBenefits, leading a significant portion of the company’s workforce across call center, client services, and general operations, as well as market strategy and performance, sales and marketing.
