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Primary care physicians (PCPs) and other physicians continue to migrate away from the traditional fee-for-service (FFS) reimbursement model toward value-based and risk-bearing care models that reward better outcomes and reduced healthcare costs. Value-based care (VBC) contracts are projected by McKinsey to cover nearly 65 million Americans, or 22% of insured lives, by 2025, up from 15% in 2021.
The trend toward VBC is clear. Yet transitioning from a volume-based transactional billing model to one that incorporates financial risk and rewards tied to the patient’s health outcome is not easy. Successful implementation of value-based programs requires PCPs and physician groups to deploy technologies that provide complex hierarchy support for contract modeling, onboarding, data capture, digitization, value-based payments and exchange. These technologies also must support Social Determinants of Health (SDoH), quality reporting and near real time data synchronization between different parties.
A VBC network consists of multiple stakeholders that may include hospitals, physician groups, payers, risk-bearing entities such as accountable care organizations (ACOs), clinically integrated networks, social service networks and community-based organizations (CBOs). Within these networks are many-to-many relationships in which an entity in one network may be engaged in several networks under various contractual engagements with other entities. An organization that offers nutrition intervention services, for example, may have contracts with healthcare providers across multiple VBC arrangements. Such a “network of networks” can work only with an infrastructure that supports the hierarchies between these entities.