The American healthcare system has come a long way in reinventing itself to deliver on the promise of value rather than volume. With the help of enabling technologies and favorable policy mechanisms, the care continuum has steadily transformed into an outcomes-driven ecosystem that is more likely to deliver health instead of simply “sick care.”
Value-based care models and their respective alternative payment structures are shepherding along this success. When providers are financially accountable for quality and outcomes, patients receive better care at a more sustainable cost.
Thanks to sustained bipartisan investment in value-based reimbursement, more than 60 percent of payments are now linked to quality and value in some way. More than 40 percent of payments flow through advanced value-based models that include enhanced financial risk — and reward — for participating providers.
But policy only scratches the surface. To maximize performance and meet ambitious quality and cost targets, providers and payers must leverage sophisticated technology to get ahead of clinical risks, engage patients, and effectively manage the revenue cycle. From clinical risk stratification and patient engagement to coding and billing, health IT tools have become absolutely essential for managing the clinical, financial, and relationship-building aspects of value-based care.
Here are three ways that health IT can help providers, payers, and other key stakeholders make the most of value-based care.
1. Population health management and risk stratification
Generating an accurate portrait of community health is the first step for allocating clinical resources, making operational investments and technology purchases, and developing initiatives that address the specific needs of a targeted group of patients. Population health analytics use various data sources to identify chronic disease trends, highlight socioeconomic vulnerabilities, and deliver deep insights into the best strategies for closing gaps in care.
By combining clinical, socioeconomic, and financial information to stratify populations by risk, these platforms allow providers to care for their most complex, highest cost individuals in a timely and appropriate manner.
Population health management tools are now widely available, with many harnessing the power of artificial intelligence (AI) and machine learning to extract actionable insights from a wide range of structured and unstructured data sources. Those insights add context to patient health, providing opportunities to deliver whole-person care.
But not all solutions are created equal. Before considering a purchase, organizations must have a clear understanding of their existing health IT infrastructure, their data use needs, their clinical transformation roadmap, and a concrete sense of their goals and expectations for any new health IT solution.
In every case, the goals must drive the technology — not the other way around. Too often, healthcare leaders hear about a tech solution that sounds useful and attempt to build new workflows to wedge that solution into daily operations. A comprehensive target model for enabling technology will help avoid misfires on solution evaluation and selection.
2. Patient engagement and consumer experiences
Both providers and health plans have multiple incentives to make chronic disease management as simple as possible for patients. In addition to shared savings benchmarks related to clinical outcomes, many plans and providers are measured on the quality of the consumer experience itself.
For example, more than two-thirds of the Medicare Advantage Star Ratings system is tied to medication adherence and member experiences. The ratings system influences financial rewards and marketing opportunities for health plans.
Providers and payers should consider implementing a range of patient-facing digital options, including:
- Convenient online scheduling, bill pay, and prescription renewals
- Online messaging with providers and real-time AI chatbots
- Text messaging to contact providers on a channel consumers prefer
- Easy access to test results and personalized care plans
Patient experiences extend to all digital technologies that keep them connected. The COVID-19 pandemic brought an explosion in the use of telehealth and created a clear, tangible use case for expanding care-at-home to remote patient monitoring (RPM) for chronic conditions and acute care services. To develop a scalable care-at-home program, care teams need to do more than just put webcams in front of patients.
Organizations must invest in robust infrastructure to ensure safety and efficacy while offering excellent patient experiences. For example, clinicians need platforms that are deeply integrated with other clinical systems. In addition, providers must adopt advanced RPM analytics tools to collect, synthesize, analyze, and report upon data from a variety of home-based digital devices.
Patient engagement with digital technologies should be user-friendly, easily integrated into existing ecosystem, and calibrated for the health literacy level of the targeted users.
3. Revenue cycle management
Managing the revenue cycle requires providers to carefully and appropriately document underlying clinical risks in addition to the services they provide, since risk adjustment algorithms have a direct impact on payment rates. Particularly within Medicare Advantage populations, accurately capturing risk scores must be part of daily routines to ensure optimal payment under capitation.
Providers have to stay aware of the billing codes applicable to their patient populations, including those that may offer enhanced reimbursement in the pay-for-performance environment, such as Medicare Annual Wellness Visits and certain transition of care activities. Clinicians must be cautious about inaccurate coding, which can lead to missed reimbursement opportunities, claims denials, or even accusations of fraud.
Lastly, both provider and payer organizations must keep track of a mix of prospective and retrospective payments. Spending caps, capitated reimbursement, bundled payments, and denials can lead to confusion and complications in the finance department.
By combining revenue cycle management technologies with population health tools and patient engagement solutions, providers and health plans can successfully navigate the changing financial ecosystem and achieve value-based care’s promises of improved outcomes, lower costs, and better patient experiences.
Let our experts draw the connections between value-based care and technology to help your business thrive in the new healthcare economy. We have a proven track record of accelerating growth for health IT innovators, hospitals and health systems through market insights and data-fueled strategies that produce measurable results. Request a quick discovery call here.