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As the health care industry increasingly shifts to value-based care (VBC) and alternative payment models, its biggest challenge is inertia. Fee-for-service (FFS) and pay-for-performance (P4P) have been firmly entrenched for years, along with the associated business processes and costly legacy systems that support them.
To fully realize VBC’s value, these existing processes and legacy infrastructures must be transformed. Health care organizations can be strongly resistant to change, however. A primary obstacle relates to sunk investments in business processes and internal systems. In both cases, existing infrastructure creates a commitment to the status quo that makes change difficult or even impossible.
Most health care IT systems are structured to enable FFS and/or P4P payment models under which the exchange of data is one-to-one. For example, a primary care physician sees a patient, generates a claim, and submits it to the payer for payment.
A VBC ecosystem requires hierarchical and far more complex relationships among providers, payers, community-based organizations, social service networks and other stakeholders in the VBC network. In addition to facilitating payments, a VBC platform must support social determinants of health, quality reporting, and other use cases.