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5 Best Practices to Advance Value-Based Care Reimbursement

Health insurers struggling to succeed in a value-based care reimbursement model may benefit from population health management, patient engagement, and healthcare delivery reform.

By Vera Gruessner

When payers begin to transition to value-based care reimbursement from the more traditional fee-for-service payment system, company executives and financial experts may find it takes longer than expected to adopt the new payment structures while they overcome some stumbling blocks. To transition more successfully toward a value-based care reimbursement system, payers may need to follow some key best practices.

Evaluate the patient population

Accountable Care Organizations

In order to move into value-based care reimbursement in an effective manner, payers will need to analyze patient population data to understand what type of care and preventive services are needed from the provider network. The results of the evaluation can then be sent to relevant medical facilities to personalize treatment for each patient.

Some strategies payers can use in evaluating patient populations include patient risk stratification and population health management analytics. Payers could help inform providers on which members are in need of greater engagement in their chronic disease management. Using population health registries for tracking a patient’s progress can also be beneficial.

In particular, population health management could help payers and providers reduce wasteful spending by tracking patients more closely to ensure preventive services are provided before a patient’s diagnosis worsens and he or she ends up in a costly emergency room visit. Payers, however, will need to remember that measuring the impact of population health management may need to be done on a longer timeline, said Daniel Palestrant, MD, Founder and CEO of par8o.

“A challenge that a lot of payers and organizations now face around population health is one of reconciling timelines,” Palestrant told last year. “Population health and the benefits from good value-based care is really measured in years.”

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“Improvements in hypertension and glycemic control – the data shows very clearly that it will have a positive impact on patient outcomes, but that usually takes years to benefit the patient and ultimately benefit the overall cost.”

Add financial risk slowly

Another strategy for moving into value-based care reimbursement involves introducing financial risk more gradually, according to a report from the Alliance of Community Health Plans.

When providers partner with payers through a value-based care payment model, they’re often required to take on more financial risk as opposed to payers taking on more risk in a fee-for-service model. The report suggests for payers to transfer financial risk onto the provider in a slow and incremental fashion while the providers advance their care management strategy.

Tufts Health Plan analyzes provider data to better understand which medical facilities are ready to take on more financial risk. Payers could follow this approach when deciding to increase the amount of risk their providers can handle.

Tailor quality measures to fit provider goals

Healthcare providers often have their own quality improvement goals for their patient population. Payers could more effectively transition to value-based care by aligning their quality measures to fit the goals of their provider networks.

Additionally, instead of forcing providers to adhere to differing quality metrics between public and commercial health plans, payers could customize their quality measures to align with that of the Centers for Medicare & Medicaid Services (CMS) and MACRA regulations.

Invest in healthcare delivery reform

The company website of the health insurer Blue Cross Blue Shield outlines the need for payers to reform healthcare delivery to better serve their membership. Blue Cross health plans are working to advance customized and coordinated care by investing in more healthcare delivery models like accountable care organizations and patient-centered medical homes.

The goals of value-based care reimbursement entail reducing healthcare spending as well as improving the quality of care. Results show that investing in accountable care organizations or patient-centered medical homes lead to a decrease in wasteful spending and a rise in quality, according to Blue Cross Blue Shield.

Empower and engage members

Another way to see the best results from value-based care reimbursement platforms is to invest in patient engagement. Members with the tools needed to make the best decisions in their healthcare shopping are more likely to choose more affordable options.

Blue Cross health plans, for example, provide their members with necessary information to find the best doctors and hospitals to fit their needs. Mobile and digital health tools have also been useful in engaging members through data-driven updates to help them make the best decisions in their healthcare purchasing.

Health insurance companies that follow the five steps above are likely to see greater success in their value-based care reimbursement plans.


Dig Deeper:

How Payers Should Prepare for Value-Based Reimbursement

Key Steps for Payer Success in Accountable Care Organizations


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