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Accelerating value-based care: Why health plans now hold the keys | Viewpoint


Health plans possess the back-end technology powering value-based models and the patient information that will empower more equitable care.

Amid an uncertain economy, providers, payers, and patients alike will be turning 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 taken center stage once again in the healthcare discussion.

During the pandemic, the industry saw a rapid move towards these pay-for-performance payment models, with one large health player quickly implementing a value-based care model in just 18 months, according to a recent analysis by McKinsey & Company. This analysis also notes that even as digital health investment has declined since 2021, private equity firms continue to place bets on innovative healthcare business models that deliver positive results, showing promise for the acceleration of value-based care adoption.

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

Health plans hold the keys to the back-end technology powering these value-based models, to the patient information that will empower more equitable care, and to the systems that will allow for 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 the data.

For years health leaders have discussed the need to consider social determinants of health (SDOH) – the factors outside of a doctor’s office that impact care – into how care is delivered 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 like LexisNexis have developed the tools to collect SDOH data. The challenge is this data is often held in siloes or delivered to providers too late in a patient’s 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 disseminate this information to every healthcare player impacting a patient’s care.

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

IMSNY built a SDOH solution centered around three components: a map of the local community-based supports for patients, a data warehouse that brings together patients’ community-based and clinical data, and a curated network designed to make closed-loop referrals to ensure the client receives the referred service. This program has allowed patients to receive whole-person healthcare, leading to better health outcomes.

Keying in on new technology to scale

To transform value-based care infrastructure with new SDOH data streams, health plans need to take a hard look at the technology they innovate with.

The reality is value-based care started as an experiment. In its early stages, health plans developed value-based care models through homegrown solutions, massive spreadsheets and labor-intensive manual processes. Compounding the problem, legacy claims and payment systems, built for fee-for-service are, at best, marginally able to support value-based care and payment models.

Now, as more providers are open to adopting these risk-based cost models, the challenge is modernizing these legacy systems to manage an influx in new value-based care contracts, while still coordinating legacy contracts.

To do this, health plans are increasingly looking towards technologies that can optimize value-based care programs for improved performance year-over-year. Health plans need technology that standardizes and automates value-based programs and adapts to provider contracting needs.

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

Opening the door to provider communications

As health plans modernize their technology stack to scale 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 around how they are performing on a contract.

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

There also needs to be more clarity for providers on how to submit patient care data to the health plan. For many plans, this process is still highly fragmented with providers submitting data from various channels. Narrowing provider dataflow to one channel with technology that can deliver fast 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 into provider data flow will be the key to push value-based and equity-based care forward.

Dr. Abhishek Jacob is the vice president of product management at Edifecs, where he heads value-based care product offerings. Fred Guthrie is the associate vice president at Edifecs, and he is product owner for the company’s population payment management business.

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