Technology Enabling the Value Revolution

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. The pandemic proved that prioritizing volume over value is unsustainable. Together, we have the power to create change. We 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. 

This is our manifesto for change. 

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THE ROLE OF TECHNOLOGY IN VALUE-BASED CARE AND PAYMENT 

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. 

Enterprise Data Management 

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, each 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 to access, aggregate, and use that data 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. 

Analytics 

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: 

• Improve clinical quality by surfacing care gaps and opportunities using the latest evidence-based guidelines 

• Lower total care costs by anticipating adverse events based on a patient’s clinical and claims history 
• Achieve operational efficiency by prioritizing necessary care and services for patient populations 
• Improve financial performance by aligning insights with the clinical and financial objectives of various contracts 

 Analytics are also essential to gauge the performance of clinical teams and providers. Administrators can use this information to pinpoint areas where VBC is working well and replicate that throughout the system. Payers and other partners can use analytics tools to evaluate the performance of specific providers or health systems as they build out a network focused on achieving value-based goals. Providers can also use analytics to boost morale by showing the significant positive impact of care that leads to better patient outcomes. 

Population Health Management 

A value-based care approach requires analytic insights to integrate deeply 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:  

• Ongoing care management to reinforce appropriate and cost-effective utilization, and support patients with chronic conditions. 
• Care coordination that links every member of a care team – primary care providers, specialists, hospitals, long-term care facilities, and home-based care – with the clinical and financial objectives of health systems, payers, and employers. 
• Clinical decision support tools that alert providers to individual patient needs at the point of care, based on analytics insights and the specifics of a risk-based payment model. 

Payment Technology 

Transitioning from a fee-for-service (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. 

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. 

Managed and Consulting Services 

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. 

Making these changes is not optional, so it’s time to either march forward on this journey or fall behind. Let’s turn the page on healthcare history together.