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For operational efficiency, value-based initiatives need a scalable digital infrastructure that can handle multiple reimbursement models, including fee for service.
Value-based care (VBC) models are designed to improve patient outcomes and reduce healthcare costs by proactively focusing on patient wellness. This preventive approach to individual and population care requires collaboration between patients, providers, payers, and other stakeholders, such as community-based organizations (CBOs) that offer wellness-related services.
Payers benefit from VBC models because their emphasis on preventive care results in a healthier overall population and better management of chronic conditions, which reduces claims for prolonged and expensive treatments. Heart disease, diabetes, cancer, Alzheimer’s disease, and other chronic illnesses combined account for 90% of healthcare costs in the U.S., according to the Centers for Disease Control and Prevention.
To get the most from their VBC models, however, payers need effective contract management, including payment capabilities, across all entities in the network. Payers must avoid replicating how they historically have managed fee-for-service (FFS) contracts – which emphasize volume – because FFS models are dramatically different than VBC ones in how reimbursements are determined and made.
For a VBC network to succeed, transparency around payments is essential. The traditional FFS claim-adjudication system is not designed to navigate the complexities, scale, and many-to-many “Network of Networks” hierarchical relationships that exist within a VBC environment. Transparency ensures a shared understanding and clarity around what is being measured, how it’s being measured, and the terms of the contract (which dictates how stakeholders are paid).