Enabling success in value-based program management

The current landscape of value-based programs: Rising growth and ongoing complexity

As the healthcare market continues to evolve, value-based programs are defining the future of healthcare service and delivery. Lofty industry goals to have 100% of Medicare and 50% of Medicaid and Commercial reimbursements tied to value-based contracts by 2025 have made it imperative for health plans to clearly develop, define, and communicate performance requirements and goals with their provider networks.

Having worked in the managed care arena for over 25 years, I have watched health plans across the United States face challenges with the development, implementation, and ongoing management of their value-based programs. Some of the most common questions we get from health plan customers include:

• • How do I know my programs are actually improving member outcomes?
  • How can I measure the performance of my provider network in a timely manner?
  • How do I empower providers in my network to engage in value-based programs and other healthcare initiatives?

Value-based contracts are being introduced across the country at an increasing rate, varying widely in both type and complexity. Even for those health plans not yet engaged in value-based models, monitoring and assessing performance across the provider network remains a key organization requirement. Processes must be in place to track performance at both the payer and provider level and contain drill-down capabilities to ensure providers are empowered with the most accurate and timely member-specific data, as well as current views of how they are performing against the contract.

Whether value-based arrangements are in place or not, health plans are challenged to:

• • Share accurate, timely quality performance insights within their organization and to their network providers
  • Improve the speed and cost-effectiveness of communicating value-based care contract results and/or provider performance on quality measures
  • Reduce administrative barriers introduced by contract management, tracking, reporting, and maintenance of ongoing program changes

Technology solutions empowering value-based program management and improvement

Industry innovation is eliminating many of the traditional challenges tied to value-based program management, oversight, and improvement. The advent of cloud-based software solutions that support real-time data exchange is enabling a greater level of transparency across health plans and physician networks. It also contributes to greater resource efficiency as health plans consolidate the management of their healthcare programs and initiatives leveraging a single solution. Beyond value-based programs, health plans are applying these capabilities to support their core quality and risk adjustment programs with seamless member and provider-specific views. With the added support of robust healthcare data sources, these solutions can help health plans identify:

• • Quality Improvement. Payers with a deeper understanding of membership, clinical and quality outcomes, and quality measure performance against trends and benchmarks are better equipped to make decisions that drive improved quality gap closure and financial performance.
  • Risk Score Accuracy Needs. With greater insight into provider average risk scores, persistency distribution, condition category status, and details into the members, payers can implement measures to ensure member disease documentation is accurate and up-to-date.
  • Areas of High Cost and Utilization. Cost and utilization reports that detail utilization specifics by facility, diagnosis, member, and cost details offer robust details for understanding care patterns and informing future resource allocation.