Historically, the U.S. healthcare system has evolved based upon the presence of an “event”, i.e., the need for a visit – planned or impromptu – to a medical provider and/or facility. The inefficiencies, glut of utilization and exponentially rising costs that flow from it as funded by the long-standing “fee-for-service” (FFS) payment methodology have been well chronicled to date. Even with the advent of a variety of risk-share payment models, medical costs remain out of control due to the complexities of operationalizing such models across a heavily siloed healthcare continuum.
Fast forward to today. In walks Value-based Care (VBC) – a payment model that aligns desired health outcomes with funding. With the Centers for Medicare and Medicaid Services (CMS) signaling a move to its exclusive use and history teaching us that where CMS goes so eventually do the commercial healthcare markets, demonstrating “outcome achievement” is now the name of the game for players in the industry. That is why industry stakeholders who currently hold the medical cost risk are investing in the rapid enablement of VBC models across their partner landscapes and beginning to directly link provider pay to the ability to demonstrate improved health outcomes for the consumer. However, this enablement goal is requiring a significant paradigm shift for both the financial risk holders and their partners, while simultaneously revealing incentives to overcoming the barriers that impede making the shift a reality – and doing so at scale.