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Embrace Value-Based Reimbursement

The move to value-based care and value-based reimbursement is gaining momentum in healthcare and will only increase over time.

For health plans, this means having the flexibility to negotiate, implement and administer a variety of contracts with providers and offer corresponding benefit plans to members.  Sharing risk as well as rewarding providers for improved outcomes and keeping individuals and populations healthy is essential.  Effective value-based contracts not only benefit patients –health plans lower medical costs by avoiding costly encounters, services and hospitalizations. There are many models, ranging from simple quality metrics to full capitation, with a full spectrum in between.

Independent Health's Success with HealthRules
Savings Achieved
Cost Reduction on 5K Patient Outcomes
PCPs in Full Capitation Contracts
Value-Based Reimbursement: How we got here, what’s working, and who’s doing it well

Payers, providers, the U.S. government, and other entities have made initial investments in value-based reimbursement. And while these initial investments have, in some cases, made great strides in the march toward quality-based care, costs are still increasing, payers and providers are no closer to a trust-based relationship, and fee-for-service is still a large part of reimbursement.

Aetna, for example, has their 2020 program, which commits to 75% of provider contracts to include a pay for value component by the year 2020.  United Health has shared that approximately half of their $100 billion in reimbursements are tied to quality, with the percentage planned to increase.  Humana serves more than two-thirds of its 1.8 million Medicare Advantage members through value-based care plans.The Center of Medicare and Medicaid Services (CMS) has been leading the transition to VBR since the passage of the Medicare Access and CHIP Reauthorization Act (MACRA) in 2015.By 2018, CMS plans to have 90 percent of Medicare fee-for-service payments in value-based purchasing categories that are linked to value-based payment.

Value-based reimbursements are here to stay and have become a required capability for health plans.  Modern, next generation technology, including your core administration system, is a key piece of the infrastructure necessary to succeed in this new world.  How is your organization embracing value-based models?

HealthEdge customers are benefiting from the flexibility provided by HealthRules solutions and forging ahead with pay for value relationships with their provider network.