Accelerated Value-Based Care: Why Health Plans Now Hold the Key

Health plans with value-based models and back-end technology that empowers patient information will empower more equitable care.

Amid an uncertain economy, providers, payers and patients alike will turn their attention to value-based care models to cut costs and improve health outcomes.

These models, where reimbursement is rewarded based on quality of care, have once again taken center stage in the healthcare discourse.

During the pandemic, the industry moved quickly toward these pay-for-performance payment models, with one large healthcare player quickly implementing a value-based care model in just 18 months, according to a recent analysis by McKinsey & Company. did. The analysis also notes that even though digital health investments have declined since 2021, private equity firms continue to bet on innovative healthcare business models that deliver positive results, driving adoption of value-based care. Shows promise to accelerate.

While COVID-19 pushed value-based care back onto the stage, health plans must now pursue this healthcare delivery model. Why?

Health plans hold the key to the back-end technology that powers these value-based models, to the patient information that will empower more equitable care, and to the systems that will allow seamless data exchange across the healthcare continuum .

Unlocking data insights to advance health equity

To carry the value-based care torch forward, health plans must unlock data.

For years health leaders have discussed the need to consider social determinants of health (SDOH) – factors outside a doctor’s office that affect care – in how care is provided to each patient. By integrating this data into patients’ care plans in a value-based care model, health plans can better assess patient health risks and help providers proactively support patients.

Data aggregators such as LexisNexis have developed tools for collecting SDOH data. The challenge is that this data is often kept in silos or delivered to providers very late in the patient care journey. Looking ahead, health plans will need to leverage technology solutions that can automate and scale their value-based care programs with SDOH data pulled from aggregators and every healthcare player impacting patient care. disseminate this information.

This work is already in progress. Innovative Management Solutions of New York (IMSNY), a joint venture led by large behavioral health practice associations, is leading the way in SDOH data integration.

IMSNY built an SDOH solution centered around three components: a map of local community-based support for patients, a data warehouse that brings together patients’ community-based and clinical data, and a curated network called Close -Loop referral is designed to ensure the referred customer receives the service. The program has allowed patients to receive whole person health care, which has led to better health outcomes.

Keying in on new technology to scale

As value-based care infrastructure transforms with the new SDOH data stream, health plans need to take a hard look at the technology with which they innovate.

Reality Values-Based Care began as an experiment. In their early stages, health plans developed value-based care models through indigenous solutions, large-scale spreadsheets and labor-intensive manual processes. Exacerbating the problem, legacy claims and payment systems built for fee-for-service are best able to support value-based care and payment models.

Now, as more providers are open to adopting these risk-based costing models, the challenge is modernizing these legacy systems to manage the flow into the new value-based care contracts, while still coordinating legacy contracts. Has been

To do this, health plans are increasingly looking to technologies that can optimize value-based care programs for better performance year after year. Health plans need technology that standardizes and automates value-based programs and adapts to provider contract requirements.

These technologies will fundamentally support data aggregation, governance and quality, a modular and reusable IT infrastructure, better policy support and compliance, improved information sharing capabilities, and a framework to support value and better outcomes. need to.

opening the door for provider communication

As health plans modernize their technology stacks to enhance their value-based care systems, improving communication with providers will be paramount. Historically, value-based care has been an opaque system for some providers, with uncertainty about how they are performing on contracts.

This lack of transparency ultimately slows the adoption of value-based care as providers are unsure whether they should or can take on new members. Health plans should provide a large window into provider performance.

More clarity is needed for providers on how to submit patient care data to the health plan. For many schemes, this process is still highly fragmented with providers collecting data from different channels. Limiting provider data flow to a single channel with technology that can rapidly deliver insights on this data will be the future of value-based care.

Health plans are the gatekeepers to value-based care. SDOH data integration, improved technology infrastructure and increased transparency in provider data flow will be keys to advancing value-based and equity-based care.

Dr. Abhishek Jacob is the Vice President of Product Management at Edifex, where he offers value-based care products. Fred Guthrie is associate vice president at Edifex, and he is the product owner for the company’s population payments management business.


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