Kristine Pelerin (kpelerin@aol.com) is the Compliance/Quality/Risk/Credentialing Manager at New York Oncology/Hematology in Clifton Park, NY.
Paul P. Jesep (pjesep@gmail.com) is the Chief Ethics and Compliance Officer at Hometown Health Centers in Schenectady, NY.
In Part 1, published in the September 2019 issue of Compliance Today, the history and development of quality and compliance and how they complement each other were discussed. In Part 2, value-based health is used as an example of how the quality-compliance partnership can and must be optimized.
Defining terms
Not surprisingly, confusion abounds about the nature of value-based care. It appears most healthcare professionals have an idea it’s coming, but no one seems to know with any certainty what will happen. Now is the time to start educating key members of your team. Provide regular updates at senior and mid-level meetings.
How an organization tackles value-based care will have similarities to other entities. At the same time, however, every organization is unique, and a strategy must be tailored to specific needs. Patient demographics, for example, will drive your strategy.
Independent of the value-based terminology, it’s good planning to look at all the terms used in the organization. Could your team distinguish insurance risk from performance risk and have a working understanding of performance measures? Are there nuanced understandings of each? Define your terms.
Know your audience
Social determinates of health (SDOH) are now a major consideration for many primary care offices. It’s a term that should be on everyone’s tongue. It’s a new concept in providing healthcare.
It has been proven that when a patient has stable housing, including heat and power, reliable healthy food sources, and a social and emotional support system, they will be more in tune with their health. Although there has been a focus on the economically disadvantaged, educated professionals and the middle class will have their own set of challenges.
Healthy People 2020 emphasizes the importance of addressing SDOH. Increasingly, one area that has improved is the portion of the population with access to healthcare and medical insurance.[1] Insurance alone, however, will not address the impact of SDOH. Just because someone has it, doesn’t mean they’ll use it. This is especially apparent in underserved populations who benefit from Medicaid but have not established the routines for regular healthcare visits and doing what’s needed for self-care.
If you’re a private practice not dealing with the challenges of poverty, your hospital or private practice will need different strategic approaches as value-based care unfolds. As noted above, be aware that the wealthy and middle class also have their own social determinates. Be mindful of looking at all the issues at play, whether state and federal policy changes, new financial challenges, and the various constituencies that will be affected.
