CMS is pushing providers to shift to value-based payment models through rewards and penalties based on performance. 90% of payers and 81% of hospitals now offer a mix of fee-for-service and other reimbursement models and by 2020 it is anticipated that two-thirds of payment will be based on complex reimbursement models with underlying value measures.
Some of the ways providers are adapting to this new reality is by consolidating practices to increase negotiating power or by forming ACOs, Patient Centered Medical Homes (PCMHs) and provider-led health plans. They are also sharing more of the risk burden of the patients they care for. To succeed in this new model, providers must understand their populations based on cost and also be able to forecast the risk of high cost and high level of care amongst members. In order to be financially viable in the shared savings scenario, risk taking businesses need to cut back on over-utilization of resources while maintaining the quality of care.
KEY MARKET CHALLENGES
- Transition from volume-based to value-based care models
- Reducing Care Variation between providers
- Standardizing care around evidence-based best practices
- Understanding and stratifying patients through the lens of cost, quality, risk, and utilization measures
- Connecting data from disparate data sources
- Engaging patients and providers to drive clinical and financial outcomes