The Business of Managing Health Over Healthcare for Health Plans

Payment models for healthcare in the US are at the crossroads. The predominant fee-for-service (FFS) model is widely recognized as a major contributor to wasteful spending and a barrier to improving healthcare delivery. To promote value and progress toward achieving the Triple Aim of an improved experience of care, better health for populations, and lower costs, health plans are turning to payment innovations centered on value. Value-based payment (VBP) programs tie healthcare provider compensation to measurable improvements in quality of care, patient health outcomes, patient experiences, and cost, often in a risk-bearing relationship.

Such arrangements are shifting the focus of health plans from strictly managing of healthcare (resource-oriented and cost-containment in a provider fee-for-service contract) to improving the overall measurable health status of the member (outcomes-oriented and value-based under provider risk-bearing contracts). Becoming an organization focused on value requires strong population health management capabilities, good provider relationships with measures that support shared goals, applied health analytics, and updated payment administration competencies. Underlying tools must enable accurately priced contracts and performance- based contract payments.

Yet, transforming into an organization that truly achieves such health value management requires modernization of technology, re-engineering of traditional processes, and an internal/external cultural makeover. Let’s break it down.

Core Operations for Health Value Management (HVM)

HVM requires ongoing provider alignment using advanced analytics, data-sharing, and consumer engagement driven through emerging risk-bearing reimbursement arrangements. Known as advanced alternative payment models (A-APMs), these contractual arrangements share or shift risk to the provider community, where calculated performance and outcomes are viewed for shared patients across the care continuum within attributed populations to determine final provider revenue.

Under A-APMs, coverage and costs are no longer the sole considerations to reimbursement. Rather, A- APMs link health value management back to specific measurements of the triple aim, correlating combined provider accomplishments directly with final payment. To do so, plans require robust   Please continue reading here 

 

Article by:

 

Adele Allison, Director of Provider Innovation Strategies 

As the director of provider innovation strategies, Adele Allison monitors healthcare reform for DST System’s health solutions division. Having served as the co-chair of the ONC Beacon-EHR Vendor Affinity Group and a current co-chair for HHS’ Workgroup for Electronic Data Interchange (WEDI) Payment Models Workgroup, Allison has over 25 years of healthcare experience. A published author, Allison is a member of UAB’s advisory board on curriculum development and serves on UAB’s HITECH Committee for health IT curriculum development; and, is a member of the board of directors for Alabama HIMSS.

Adele Allison

 

 

 

 

 

 

 

 

 

 

 Amy Salls, Director of Revenue and Quality Analytics

Amy Salls_Bio

 

 


Tags: Health Value Management, Advanced Alternative Payment Models, Population Health, value-based care, volume-to-value

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