Changing Landscape of US Healthcare

For years, the most prominent model of healthcare delivery was fee-for-service. The patient would approach the provider for treatment in exchange for reimbursement by the patient’s payer. This was a very transactional interaction where the treatment results were not tracked and healthcare costs simply kept spiraling. The reason: progress of the patient’s health condition was inconsequential to healthcare organizations; they were paid for the treatment provided regardless of the outcome. Eventually, there was a realization, especially among regulators, that there is  need for a new direction that ensures the ultimate wellbeing of the patient.

This gave way to the introduction of value-based care. Under this new paradigm, the focus was on the patient. Providers would be reimbursed based on the patient’s health outcomes. This evidence-based approach ensured higher quality in care delivery and curtailed healthcare costs. This would specifically benefit patients with chronic conditions. Providers would have the incentive to work towards bringing down the incidence of such diseases in new patients and lowering their impact in existing patients.

Value-based payment programs are now present in as many as 48 states and 50% of these programs are multi-payer in scope1

All Healthcare Stakeholders Stand to Benefit

  1. Lower costs – Chronic diseases like cancer, high blood pressure, diabetes, etc., demand ongoing care and healthcare bills keep piling up. If the focus is on a healthier lifestyle, they will recover faster and have fewer doctor’s visits. Naturally, spends on medical procedures and prescription medications will be contained.
  2. Lower health risks – Mortality as well as chances of acquiring new diseases are risks that can be curtailed. This leads to fewer claims, which further help reduce the burden on payers’ pools.
  3. Better quality ratings, provider efficiency and patient satisfaction – Quality of care is the key focus in value-based programs. It ensures that providers do not waste time and resources on unnecessary tests and procedures. Financial gains from volume-based care cease to remain the driving force for providers. This ensures better patient care, which leads to better patient experiences.
  4. Increase in supplier profitability – The products and services of suppliers get automatically aligned to patient outcomes. This reduces costs and improves the efficiency of the whole ecosystem. Individualized therapies might witness tying up of drug prices to actual value the patient derives.

Pay-for-Performance Programs

There are numerous quality-based programs that have been formed by various health stewards to help organizations keep track of their performance with regards to delivering quality care to patients. The idea is to measure performance across key quality metrics as defined by the steward. In return, the providers are reimbursed only if value has been delivered to the patient. HEDIS and MIPS are two examples of such programs. These programs monitor aspects of healthcare delivery such as quality, effectiveness, patient experience, etc. Thus, the concept of financial incentives is more redefined when compared to the earlier fee-for-service model.

Role of Data

The healthcare ecosystem is comprised of huge data reservoirs such as medical records captured in EHR, lab results, insurance claims, patient demographics, clinician notes, etc. All this data provides a great opportunity to analyze performance across the care continuum and identify insights to guide patients towards a healthy path. The volume of data is increasing at an unprecedented pace. Today, there is a need for  big data architecture implementation together with advanced analytics and machine learning algorithms to derive actionable insights.

Physicians and provider members must be made aware of these insights to reduce costs, improve efficiency of the system and help patients lead healthier lives. One of the primary objectives of value-based care is population health management. A comprehensive view of the member is imperative to make it possible. Here’s how it can be achieved: Clustering techniques to segment the population based on similar characteristics. Predictive analytics to identify a set of population that is most likely to remain noncompliant with expected health standards. Focused attention and new strategies can then be executed to deal with the illnesses of such patients.

Using descriptive analytics, we can find out critical areas to focus on for each quality-based program. This will help in not only improving provider performance and score but also in identifying the right levers to achieve higher financial profitability.

The ITC Infotech Advantage

ITC Infotech’s Healthcare Insights platform is NCQA certified and has a state-of-the-art quality management solution called Quality Maximiser, which comprises of predefined quality measures (regulator driven or defined in-house), business workflows and advanced analytics capabilities to engage members effectively for gap closure and improved member experience.

The performance across programs can be visualized through highly insightful dashboards. Predictive and prescriptive analytics are applied to identify members in need of interventions and recommendations for their wellbeing.


Abhinav Gupta Lead Consultant

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