The traditional fee-for-service reimbursement model has caused a deep-seated mentality that encourages more and more services. In turn, this mentality has contributed to the trend of seemingly unstoppable increases in healthcare costs and insurance premiums for millions of commercially-insured people.
The resulting tension between payers and providers causes each side to approach the other from opposite ends of the healthcare spectrum. Payers and plan benefit sponsors have implemented difficult measures such as increased pre-certifications and higher barriers of authorization along with unit price contract rate reductions. Providers are then incented to do more instead of providing more efficient patient care.
These measures have not yet slowed the increases in healthcare costs, but have only served to increase the ire of the provider community putting them at greater odds with the payer community. Patients are caught in the middle, often exposed to surprise billing and financial harm. They may also experience clinical harm from potentially avoidable procedures.
Value-based care initiatives have attempted to bring these parties back together, united under the same goals to reduce costs and improve patient care. While a few models have succeeded, many have failed because they lacked the right provider and payer engagement plan and ability to execute.However, planned and well-executed prospective bundled payment models can successfully unite payers and providers through common value-based care goals and mutually beneficial outcomes.