Transitioning to Value-based Care: Accelerated by Data Analytics and AI Solutions

Data shows that the US national healthcare expenditure is forecast to surpass USD 6.2 trillion by 2028 as per the Centers for Medicare and Medicaid Services (CMS). “On average, a US citizen spends about $12,000 on healthcare each year, and the average hospital stay runs $2,873 per day,” according to Kaiser Family Foundation.

The healthcare industry has realized that it’s time to bring in a radical change in the fundamental system of care delivery—move away from Fee-For-Service (FFS) and adapt to deliver patient-centric care. On that ground, the concept of Value-based Care (VBC) has emerged and become one of the most discussed topics in the healthcare market presently. Improved health outcome is the focus of this model contrary to the FFS approach of rewarding the volume of services. Value-based care solutions powered by advanced technologies bring down medical costs significantly, especially at a time when healthcare expenditures are soaring worldwide.

A Steady, Not Slow Progression

The global value-based care payment market is expected to reach USD3.40 billion in 2026 at a compound annual growth rate (CAGR) of 11.5%.

– Value-based Care Payment Global Market Report 2022

There has been a steady progression towards value-based care, particularly since the COVID-19 pandemic. In the US, government interventions like the Medicare Advantage, Bundled Payment Models, and Accountable Care Organizations (ACOs) among others have been fast-tracking the advancement, taking VBC to the masses. However, one can also say that although the road to VBC has been discovered and its benefits are being actively acknowledged, it is yet to be fully explored.

“The transition from fee-for-service to pay-for-value has been referred to as one of the greatest financial challenges faced by the US healthcare system”

– HIMMS

As healthcare transforms into a digitally forward industry to shape VBC into a sustainable model of care delivery, the focus is on addressing some of the biggest challenges faced by the healthcare industry. Health inequity, lack of interoperability, workforce shortages and hospital shutdowns, inadequate quality healthcare for the rural population, medical education system lacking focus on value-based care, and rising claims denials—are just some of the numerous roadblocks in the US health system that are making the adoption of value-based care an urgent necessity.

For instance –
  • Absence of interoperability has been one of the main reasons for healthcare organizations running into revenue losses. These enterprises face the risk of reputational damage as they fail to satisfy quality measures like Healthcare Effectiveness Data and Information Set (HEDIS®) and CMS Star Ratings of a VBC model.
  • Medical claims denials have risen to 11% across the US since the onset of COVID-19 according to the Change Healthcare 2020 Revenue Cycle Denials Index. CMS data reveals that 30% of claims are either denied, lost, or ignored.
  • Rising medical expenditures along with- instances of billing negligence are increasing medical debt, which has become a growing economic concern. CFPB’s Complaint Bulletin found that approximately 15% of the 750,000 debt collection complaints were about attempts to collect a medical debt that was already paid, or did not belong to the complainant, or the bill amount was incorrect.
  • More than 400,000 healthcare workers have made an exit from care delivery since the pandemic, according to the US Bureau of Labor Statistics.

Amidst such growing concerns in the healthcare system which are also impacting the US economy, embracing a care delivery model like VBC that creates value for every stakeholder in the healthcare delivery chain has been evaluated as a worthy solution in the long run.

The 3 Cs of Value-based Care Delivery — Care Quality, Cost Control, Consumer Engagement, and More

A value-based care model when implemented strategically ensures profitability to the payer and the provider while also delivering value to the end consumer (read: patient) of the service.

Better care coordination and quality of care lead to faster patient recovery. The patient needs fewer follow-up visits to the doctor, medical tests, and prescription medication which can otherwise be cost intensive. This cost reduction across the board benefits all three prime stakeholders of the system – the payer, the provider, and the patient.

With the focus of VBC on preventive care, chronic disease management, which is an area of significant concern in healthcare, also gets addressed to a great extent. Enhanced patient engagement translates to increased awareness of the positives of a healthy lifestyle. All this combined leads to enhanced patient satisfaction and value creation—the real purpose of embracing the value-based care approach.
Get a Head Start
VBC needs a holistic approach. It’s a long-term commitment that must revolve around an organization’s core capabilities and evolving market trends. And when done right, it can yield deep-rooted benefits and merit.
Data Analytics, AI, Automation, and other digital technologies are the means to the goal. Strategic planning, along with the selection, implementation, and optimization of the right AI technologies truly makes a difference in this journey.
When there’s a lack of interoperability, data integration and analysis become a challenge, slowing down the pace of VBC adoption. Compromised data literacy and business intelligence impact clinical and business operations. It is here that pairing the right intentions with the right technological know-how becomes vital.
To that end, healthcare organizations are investing heavily in data-led tools and AI technologies to make evidence-based decisions and shift to this value-centric care model seamlessly.
KANINI’s digital transformation framework and AI solutions for healthcare are built on a 360-degree transformation approach, keeping the patient at the core of every offering. Integrated Platforms for Claims, EHR, EMR, & Clinical Management, Medicaid Management & Provider Management, and Regulatory & Compliance Monitoring—are some of the AI-powered gears that are bringing transparency into the care delivery system, the very essence of the VBC model. Reach out to us to know more about how we are helping healthcare enterprises like yours thrive and evolve into patient-centric entities.
For Quick Facts and Figures on Value-based Care, Download the Fact Sheet.
Author

Rakesh Talreja
Rakesh Talreja is spearheading the Healthcare Business Unit at KANINI. He is a veteran Healthcare IT market leader, bringing 25 years of experience working with some of the best IT organizations across India and the US. Rakesh has a successful track record of delivering high customer value and creating an environment of growth.
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