It should come as no surprise when we say the U.S. healthcare system is in a state of crisis. In fact, it has been for some time. Health experts from a wide variety of industries – payers, providers, employers, population health professionals, and even patients – all know a fee-for-service system is unsustainable, and the time to talk about the problem has come and gone. Our only option now is to march forward toward a more sustainable and effective healthcare system. Those who don’t will fall behind.
A healthcare value revolution is underway, and there can be no spectators on the path to enhance care quality, reduce costs, and improve health outcomes.
The outlook for Americans’ healthcare wasn’t always so dire. In 1970, the U.S. spent about 6% of gross domestic product (GDP) on healthcare. That was comparable to the 5% average in 11 similarly developed countries, based on data from the Organization for Economic Cooperation and Development (OECD).
But in the early 1980s, U.S. expenditures on healthcare started to diverge from our international counterparts. By 2010 our spending was 75% higher than the OECD countries’ average. In 2021, we spent more than double our peer nations: $12,318 versus just $5,932 per capita.
Some may argue that the high costs have contributed to the best healthcare system in the world. Indeed, America has some of the world’s mostly highly trained healthcare professionals. We also have some of the most advanced medical technologies and innovative therapies.
But the majority of this exceptional care only helps patients who are already sick. Meanwhile, we have minimal preventive care to address the root cause of our most pressing health issues or to help people maintain better health by limiting the need for acute care interventions.
Additionally, our high healthcare spending has not translated to dramatically better quality of life or health outcomes. The U.S. ranks at the bottom in an OECD comparison in four out of five categories according to a 2021 report by the Commonwealth Fund, including:
Americans’ life expectancy is also low compared to other nations. In 1980 U.S. average life expectancy of 73.7 years was only slightly below comparable countries’ average of 74.5 years. By 2020, we ranked 28th in the world with a life expectancy of just 78.7 years, almost six years lower than top-ranked Japan (84.2 years). In the last two years U.S. life expectancy dipped to 77 years – the biggest decline since World War II – further widening the gap between us and much of the developed world.
When it comes to chronic disease, the U.S. far outpaces our peer nations. The Centers for Disease Control and Prevention (CDC) reports that 60% of Americans have a chronic disease, and 40% have two or more. And only 8% of U.S. adults get all their recommended preventive screenings and care.
The National Center for Chronic Disease Prevention and Health Promotion published a report in 2021 on how poor overall population health impacts the nation’s ability to compete economically on the world stage. This “U.S. health disadvantage” means companies spend more on employee health benefits, but get lower levels of productivity and competitiveness.
We are spending drastically more, living shorter lives with more chronic illness, and experiencing far worse health outcomes than our global peers. It may sound hyperbolic, but the health and prosperity of our nation is literally at stake if we do not make dramatic changes.
Our fee-for-service (FFS) system is filled with perverse incentives that prioritize volume over quality care and patient outcomes. This FFS system drives many of the wrong behaviors. Even providers who want to deliver the best possible care must focus on seeing more patients ordering more procedures to sustain financial viability. They have limited time and attention to establish whether care actually leads to better outcomes.
A volume-based system is counterproductive to the health and well-being of a population. In this system, people primarily seek care after they get sick, but acute interventions do nothing to prevent disease. Volume-based systems also leave fewer resources for prevention efforts. In spite of our nation’s high levels of chronic disease, FFS does nothing to incentivize care that could halt or minimize disease progression and improve peoples’ health over time.
Fee-for-service is unpredictable as a long-term business strategy. The COVID-19 pandemic brought the volatility of FFS starkly into view, as hospital and clinic volumes evaporated literally overnight. Providers and hospital systems were left without a backup plan. America’s hospitals now face “significant, ongoing financial instability” in the wake of COVID-19, according to the American Hospital Association.
Another disruption in care volumes could devastate large segments of our hospital system. One study by Kaufman Hall projected that hospitals would lose $54 billion in 2021 because of COVID-19. Thousands of hospitals in the U.S. – particularly smaller hospitals and those in rural areas – were already operating on the edge of financial viability when the pandemic hit. Rural hospitals serve 20% of the U.S. population (around 60 million people). Our volume-sensitive FFS system is working against our care delivery system, which could lead to facility closings and leave millions with no access to care.
A volume-based system is not contributing to a healthy, thriving workforce. Employers are paying a higher price every year for insurance coverage, but that is not improving workforce health. A Milken Institute study estimated that the economic burden of chronic disease is costing U.S. employers $3.7 trillion a year in both direct healthcare costs and indirect costs related to lost productivity and missed work days.
Significant barriers slowing our transition from FFS to value-based care up to this point include:
Proactively trying to reduce hospital usage, decrease emergency department (ED) utilization, and keep patients out of doctor’s offices with more effective preventive care and disease management strategies threatens the legacy business models of every participant in the healthcare ecosystem.
Dr. Clay Christensen, the “architect of and the world’s foremost authority on disruptive innovation,” co-authored a whitepaper on How Disruptive Innovation Can Finally Revolutionize Healthcare. In it, he and the other authors note the “fundamental disconnect between what patients need in order to maximize their health and what they actually get as consumers: more services and treatments that generate revenue.”
Providers, hospitals, and payers are reluctant to upend their traditional revenue drivers. This concern stems from decades of working in a fee-for-service model that only rewards volume.
But the consequences of “business as usual” are alarming. We must take steps to change both the care delivery and payment models to better align patient needs with healthcare system incentives.
“[Fee-for-service creates a] fundamental disconnect between what patients need in order to maximize their health and what they actually get: more services and treatments that generate revenue.”
In 2020 healthcare spending accounted for 20% of U.S. gross domestic product (GDP). The Centers for Medicare and Medicaid Services (CMS) projected healthcare spending to increase an average of 5.3% per year, and PwC projects that U.S. GDP will increase by about 2% per year through 2050. If these trends continue, healthcare will account for 57% of U.S. GDP by 2050 – almost $6 out of every $10 we spend in the U.S. economy.
At those rates, healthcare spending would eventually exceed GDP around the year 2067. We recognize that this hypothetical future is as unrealistic as it is undesirable. The country cannot spend every dollar we generate in our economy on healthcare, leaving no money for housing, food, consumer goods, and other necessities.
But the gap between GDP and healthcare spending is closing every year. The longer we continue to operate in an unsustainable FFS system, discussing the problem without making drastic changes, the closer we get to a future where a significant part of our GDP goes only toward healthcare.
U.S. GDP growth projections derived from PwC, The World in 2050. Healthcare spending growth projections derived from CMS National Health Expenditure (NHE) data, as well as report from Deloitte, Breaking the Cost Curve. GDP projections beyond 2050 are estimated using the average of all the years between 2020-2050. These projections depict a hypothetical (and undesirable) future if current average GDP and healthcare spending increases continues indefinitely.
Medicare’s Part A hospital fund is also running out of money. Current estimates project that the fund will only last through 2028 without a major overhaul and quick action by Congress (both of which are unlikely in the short term).
Most Americans (56%) get their healthcare through an employer. As insurance prices perpetually increased over the last several decades, employers shifted more of those costs to employees. About 75% of respondents in a McKinsey survey of employers said they have already increased, or plan to increase, the share of costs borne by employees.
Annual premiums are rising much faster than wages. Now we’ve reached a breaking point: employees cannot afford to take on any more costs, and employers cannot afford to allocate more company resources to cover insurance.
When consumers have more out-of-pocket costs from things like high-deductible health plans (HDHPs), they are less likely to seek out preventive care and comply with disease management programs. This can:
Kaiser Family Foundation found that almost half of adults (46%) don’t currently have enough savings to cover their annual health insurance deductible. That number is likely higher for people with HDHPs.
One key to a thriving healthcare system is highly qualified and trained healthcare professionals. But the relentless demands of a FFS system is contributing to serious workforce burnout. When healthcare workers must prioritize volume and throughput, they cannot spend enough time with patients to have a meaningful impact on quality outcomes. It is a frustrating reality for people who specifically chose a career in medicine to help others.
The current technology ecosystem is complex and disconnected, creating more work that results in higher costs and redundant care. But there’s little incentive to eliminate redundancies when people continue to get paid for these services.
FFS systems do not incentivize teamwork and care coordination and workflows that improve efficiency and effectiveness. Administrative burdens in a complex system also place more demands on both clinical and non-clinical employees. Gartner found that all these factors – technology, ineffective teamwork, and administrative burdens – are increasing healthcare worker burnout.
All of this is driving people out of the healthcare profession. The Mercer U.S. healthcare labor market report predicted low-wage healthcare jobs (such as CNAs and MAs) will face a 3.2 million worker shortage within five years. The American Nurses Foundation projects that as many as 52% of nurses plan to leave their clinical practice, leading to a potential shortage of one million nurses by the end of 2022.
A similar trend among primary care providers and behavioral health professionals is also possible, with 60% to 75% of providers reporting burnout symptoms. The American Association of Medical Colleges predicts a shortage of between 37,800 and 124,000 physicians by 2034.
Burnout and worker shortages also have serious implications on care quality. When providers and clinical employees are overworked, stressed, and burned out they are more likely to make mistakes. Medical errors can lead to severe and long-lasting consequences for patients, requiring more expensive care in places like EDs and hospitals.
Healthcare has seen its share of innovations that improved health, increased life expectancy, and led to better quality of life. In 1796, Edward Jenner injected a 13-year-old boy with the cowpox virus and discovered that the boy became immune to smallpox, leading to the world’s first vaccine.
Throughout the 1800s we saw advancements and discoveries that included anesthesia for surgery (1846) and the adoption of sterile surgical procedures (1860s). In the late 1800s the first X-ray machine gave doctors a view of bones and organs inside a patient’s body. It also opened the door to other imaging technologies like CT and MRI that give doctors incredible insights and contribute to better treatment plans and preventive care.
By the early 1900s, researchers discovered antibiotics that could cure bacterial infections. In 1954, U.S. surgeons Dr. Joseph Murray and Dr. David Hume successfully transplanted the first human organ (a kidney) in Boston.
Screenings developed in the 1960s and 1970s for cancers – such as mammograms and colonoscopies – gave us new tools to fight deadly diseases. In the early 2000s, physicians at the Mayo Clinic developed and deployed a team-based, interdisciplinary care model. In 2020, the highly effective COVID-19 vaccine was the fastest vaccine ever developed in human history.
Now there is another critical healthcare revolution underway: the value revolution. We are in the midst of a dramatic change that will enhance well-being, increase life expectancy, and improve patients’ quality of life with better care delivery and payment models.
Value-based care is an innovative healthcare model that moves us away from the current fee-for-service system where payment is based solely on the volume of care, to a system where reimbursement is based on the quality of care and patient outcomes. It’s not about spending the lowest possible amount on each patient. Instead, it is about spending the right dollars, at the right times, in the right places to optimize patient health.
In a value-based care world payers, providers, and employers have a responsibility to not only provide “sick care” for acute patient needs, but to be proactive in facilitating better health and financial outcomes for our entire population.
Payers and employers have a shared interest in getting the most out of healthcare dollars spent for healthy beneficiaries and employees. Providers want to deliver exceptional care, but their incentives need to align with the collective goals of delivering high-quality care and decreasing costs.
Value-based care is a dramatic change – and adoption has been slow as a result – but now the pieces are in place to move the revolution forward.
Currently around In a 2022 analysis published in the New England Journal of Medicine, authors evaluated the success of ACO programs. Organizations in the ACO Investment Model achieved more than $380 million in savings between 2016 and 2018. These 483 ACOs serving more than 11 million Medicare beneficiaries performed better on care coordination, patient safety, and quality metrics than other organizations in the Merit-Based Incentive Payment System (MIPS).
A 2021 Value-Based Care Report by Humana also showed that members in a VBC cohort were highly engaged. They followed through with screenings and preventive care more consistently and achieved higher Healthcare Effectiveness Data and Information Set (HEDIS) scores than members in the non-VBC cohort.
A 2019 McKinsey report evaluated the impact of VBC arrangements on health system margins. It found that with just 1% to 2.5% of revenue at risk in a VBC arrangement, health systems had the potential to increase margins by 20% to 50%. These arrangements offered more upside opportunity than even health systems’ most profitable service lines. All of these reports and studies reinforce that VBC can work when implemented correctly.
Since launching VBC programs, CMS and commercial payers rolled out financial incentives that connect payments to quality and outcomes. To encourage buy-in, early models offered bonuses with little or no downside risk, but those have not achieved the kind of long-term savings required to overhaul our FFS system.
“The most promising APMs today increase quality and improve outcomes while reducing total costs.”
However, there are very encouraging developments that can help us accomplish our goals. Some look familiar but include more robust tools and incentives for enhanced viability. The most promising APMs today include:
These models increase quality and improve outcomes while reducing total costs. They are also the most economically viable for providers reducing the share of FFS payments as a percentage of total revenue.
One of the key reasons some of the early efforts at reducing costs failed to take hold was the inability to scale these models. Without technology to collect and analyze data, use that data to make decisions that improve care, and administer APMs, the tools to move from FFS to value-based programs just weren’t there.
Today, we have technology that enables value-based care delivery and payment with:
The technology available today has matured beyond basic EHRs and fee-for-service claims processing and will be an essential part of the value revolution.
There are many different players in the U.S. healthcare ecosystem that must work toward a common goal. Fortunately, all the actors in this value revolution – the payers, providers, employers, and patients – have aligned interests.
As each stakeholder takes the steps necessary to improve care quality, access, and outcomes, cost savings naturally flow from:
Value-based care establishes shared objectives around providing appropriate care, preventing disease, and improving outcomes. Everyone wins with this approach – most importantly the patients.
Payers, providers, and employers all have a role to play in creating a better U.S. healthcare system. But nobody has to do this alone. The value revolution demands the focused attention and action of all of us working collaboratively for a better healthcare future. The tools we need are in place. The interests of all the participants in the healthcare system are aligned.
Now is the time for action, and we can either march forward or fall behind. There can be no spectators as we forge a new path in this value revolution.
Value-based care shifts the care delivery paradigm from treating people after they get sick to preventing sickness and slowing disease progression. It also incentivizes the right behaviors through APMs that align reimbursement to activities which reduce risk and improve health outcomes.
These once-lofty goals are now attainable. The key to success is having the right technology in place to support those efforts.
The volume of patient data is growing exponentially. Each U.S. patient generated an estimated 80 megabytes of data per year in 2017 from things like imaging, labs, and electronic health records. And that doesn’t include the volume of personal health data stored with payers and employers. RBC Capital Markets projected that healthcare data would grow exponentially between 2018 and 2025, surpassing all other industries with a 36% compound annual growth rate (CAGR).
Since most patients get care from multiple clinics and providers, and many will switch insurance plans during their lives, a person’s health record and payment history is fragmented. Providers, payers, and employers who want to use historical data to improve care find it challenging at best, and impossible at worst.
Enterprise data management (EDM) solutions are necessary to pull in data from disparate systems, then standardize the information to make it usable across an entire platform. When your data is uniform and consistent, the people in your organization can leverage it within multiple applications and programs to generate insights.
Once you have the data you need in a format you can use, a comprehensive analytics program can produce clinical and financial insights. Providers, payers, and employers all rely on data to evaluate care and services. But most analytics tools don’t offer the level of insight necessary to take actionable steps toward improving care in the future. Advanced predictive and prescriptive analytics can accelerate value-based care initiatives by highlighting specific ways to:
Analytics are also essential to gauge the performance of clinical teams and providers.
A value-based care approach requires analytic insights to be deeply integrated with care management and care delivery workflows. That means viewing patient interactions through a lens much wider than one exam or service. Population health software must enable:
Transitioning from a FFS payment model to value-based and risk-oriented arrangements requires new payment technology that supports the unique claims adjudication process of APMs.
FFS payment systems are often complex and require extensive resources to bill for services. A substantial number of claims today have errors, leading to payer rejection and additional administrative work. It wastes billions in an already inefficient system.
Transitioning from a FFS payment model to value-based and risk-oriented arrangements requires new payment technology that supports the unique claims adjudication process of APMs.
However, the shift to value-based payment arrangements doesn’t automatically make claims adjudication easier. That is especially true when payers and providers try to improvise with legacy revenue cycle systems not designed specifically to handle value-based care payment contracts. Staff must intervene manually to make these systems work, further increasing administrative costs, erasing some of the VBC savings, slowing the process, and frustrating everyone involved.
Today’s APMs require new technology with advanced logic to handle multi-faceted contractual arrangements and multiple entities coordinating care. That includes innovative payment models such as bundling and capitated payments, as well as quality-based payment bonuses and penalties.
Beyond the technology infrastructure, value-based care and payment requires an evolution of clinical and business processes and the people that power them. Most organizations don’t have the capacity to manage it all, but that doesn’t mean you should give up on value-based care entirely.
Instead, find the right balance of managed and consulting services that can help you learn and build a sustainable self-service value-based care model. Experts can recommend an appropriate strategy and software-as-a-service (SaaS) tools that build on your existing people, processes, and technology to select the right value-based arrangement and execute it efficiently.
With this knowledge and these tools, you can evolve and adjust as you discover new and better ways to achieve your goals, reducing expensive consultant costs down the road.
Enterprise data management (EDM) solutions are necessary to pull in data from disparate systems, then standardize the information to make it usable across an entire platform. Advanced predictive and prescriptive analytics can accelerate value-based care initiatives. Today’s APMs require new technology with advanced logic to handle innovative payment models.
Cedar Gate Technologies was founded in 2014 with the goal of building a technology solution to empower payers, providers, and employers to excel in value-based care. At that time, most healthcare players were struggling to see how VBC was feasible in a FFS-focused world.
Founder, Chairman, and CEO David B. Snow, Jr. had the vision of a comprehensive end-to-end solution that would meet every technical aspect of VBC: data management, analytics, care management, and payment. He acquired and integrated best-in-class technologies developed by five leading healthcare IT companies to create the industry’s most complete platform. Today, VBC-focused organizations can compose the platform to succeed in any payment model in every line of business.
The company is led by an expert team of successful healthcare operators with a track record of innovation and positive change in the industry.
Cedar Gate operates with a single mission: to provide the technology platform that enables payers, providers, and employers to succeed in a value-based care landscape and thrive in the value revolution.
To accomplish this, our solution:
In addition to our innovative leaders, many healthcare revolutionaries are joining Cedar Gate in our mission to achieve better outcomes for everyone.
CJ Stimson, MD, JD
Chief Medical Officer, Employee Health Plans
Senior Vice President, Value Transformation
Vanderbilt University Medical Center (VUMC) partnered with Metro Nashville Public Schools (MNPS) to create bundled payment options in an effort to reduce costs and improve care. CJ Stimson, MD, JD, chief medical officer of the Vanderbilt University Medical Center and Vanderbilt University Employee Health Plans, initially suggested they look at musculoskeletal procedures (such as hip and knee replacement, which are common in bundled payment plans). But MNPS had another idea based on the unique needs of their employees: how about a maternity care bundle?
Together, VUMC and MNPS developed the MyMaternityHealth program, which saved money for both the employer (MNPS) and its employees, while dramatically improving clinical outcomes for expectant teachers and their babies.
VUMC collaborated with Cedar Gate to remove one of the biggest barriers to the successful delivery of provider-led bundles – who pays for what and when. Cedar Gate’s robust technology platform enabled VUMC to throw out old fee-for-service rules and confidently move to a valued-based payment model that supports financial risk and offers a streamlined financial experience for patients and employers.
In the first year, MNPS saw more than $400,000 in total program savings, a decline in c-sections from 40% to 29%, an increase in healthy births, and a 16% decrease in NICU spending. They also tracked Net Promoter Score (NPS) to ensure high levels of satisfaction. That score is consistently in the 90th percentile. Vanderbilt now offers 10 bundles ranging from bariatric and musculoskeletal to cochlear implant and plans to add two more in 2023.
The transition to risk-based models is not a one-size-fits-all journey, and it’s not something you can turn on full speed whenever you want. Some healthcare players are well into this journey and ready to dive into more complex arrangements like two-sided risk, prospective bundled payments, or capitation. Others are at the beginning of the process, still learning how to effectively use analytics tools to identify, address, and report on quality metrics in the MSSP BASIC track.
No matter where you fall on that continuum, Cedar Gate’s platform is designed to help you succeed in value-based care. Adopting enabling technology is an incremental process with a learning curve that is unique to your organization, the needs of your population, and the requirements of your care and payment contracts.
With Cedar Gate you can start with an application that solves a specific challenge, then build over time as your organization becomes more adept in value-based care, and ready to take on more risk. Every module is seamlessly integrated within the platform, giving you the resources to execute even the most complicated VBC contracts and payment arrangements with ease.
Value-based care aligns the interests of every healthcare participant, including payers, providers, employers, and patients. We all want:
The Cedar Gate platform offers transparency in data and workflows that stakeholders need to work together toward these common objectives. When everyone has the necessary tools to align care plans with financial priorities of lowering healthcare costs, we all realize the ultimate goals of value-based care.
Everyone has a role to play in the value revolution. This transformation will not happen without the concerted effort of all healthcare participants working in partnership toward common standards and goals.
We know the trajectory we are on in healthcare is unsustainable. It’s not easy to move out of our fee-for-service comfort zone, but it is essential. Our path forward is clear, and it will lead to a future that offers every participant the opportunity to create a better and more sustainable healthcare future.
Cedar Gate has the technology to enable this value revolution where there can be no spectators. We invite you to march forward with us on this journey.
The right solution for your value-based journey is only a click away. Our modular technology is quickly and easily integrated into current systems and complements existing IT investments so that we can grow with you. Learn more today!
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