Resources

Clinically integrated networks (CINs) are gaining traction as the collaboration model of choice to enable higher quality health care at lower costs. These partnerships of like-minded independent providers and hospitals with shared performance improvement, quality, value, and efficiency goals can have a profound impact on patient outcomes while decreasing overutilization.

Value-based care (VBC) reimbursement models are designed to reward better patient outcomes while reducing the costs of healthcare. The American Medical Association (AMA) identifies several components necessary to make a VBC ecosystem successful. These include a clear, shared, patient-centric vision, the leadership and professionalism of healthcare workers, and broad access to care for anyone who needs it. 

The U.S. healthcare system’s transition away from fee-for-service toward value-based care represents the most significant change in how healthcare is delivered and paid for in generations. According to a recent study by McKinsey, the percentage of the insured population in value-based contracts is expected to grow by 10% per year from 2022 to 2025.

SDoH include environmental and social factors such as employment status, income level, education level, housing security, physical activity, neighborhood safety, and access to healthy foods. Research shows SDoH have as much as an 80% impact on the health of an individual or population. Additionally, studies have confirmed a link between SDoH-related risk factors and chronic diseases (such as hypertension and diabetes), which together account for 90% of healthcare spending in the U.S.

Value-based administration empowers payers, providers and CBOs to share patient information, coordinate care and deliver needed services, all while holding network participants accountable for the cost-and-quality metrics they committed to in risk-sharing arrangements. Few legacy systems are up to that task. 

Healthcare organizations have been on a long, winding road to value-based care, but the promise of improved patient outcomes and reduced costs is nearing as value-based care gains traction.

Existing claims and clinical workflow-based legacy technology investments, both on the payer and provider sides, simply are not equipped to efficiently administer value-based arrangements at scale.

As more payers and providers implement value-based care (VBC), treatment increasingly is shifting to a patient’s home or community setting. For payers, integrating community-based organizations (CBOs) into traditional care networks offers both an opportunity and challenge.

The growing popularity of value-based care (VBC) reimbursement models is driven by the desire to improve patient outcomes while lowering health care costs for providers and payers. Among the latter group are employers that either provide health insurance to employees through a health plan or self-funding.

Even the highest-quality medical care cannot overcome all of the factors patients encounter that lead to poorer health outcomes. One highly cited study attributes 81% of outcomes to socioeconomic factors and health behaviors and just 16% to clinical care.

The transition from treating patients at a provider’s site to delivering care in the home and community requires two things: an ability to incorporate social determinants of health into the care coordination process and the inclusion of value-based care and community-based organizations as compensated care delivery partners in value-based care networks.

The tepid relationship between health equity and value-based care became all too real during COVID-19. Vulnerable populations were severely impacted by the pandemic, resulting in higher infection rates and deaths.

Unlike traditional fee-for-service healthcare, VBC emphasizes keeping people well over “sick care.” As a holistic approach to healthcare, VBC can leverage social determinants of health (SDoH) to develop individualized care plans and to inform population health strategies.

To fully leverage SDOH information and provide more complete services throughout the care continuum in support of value-based care, payers should include community-based organizations (CBOs) in their value-based care network contracting strategies. Doing so creates a broadened, higher performing set of resources to keep people healthy and at home.

Value-based administration for whole health in the home and in the community is what we do at HSBlox.  It's about leveraging social determinants of health (SDoH) to implement value-based care. True and successful value-based administration operationalizes the value-based care continuum of capabilities that exist where value-based care and precision health intersect to create value-based plan design.

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.

The global population health market is expected to reach $91.4 billion by 2026, up from just $21.4 billion in 2018. Those in the health care trenches understand that this is due primarily to the growing shift from fee-for-service reimbursement to value-based care. As providers and payers move deeper into population health and value-based case, one thing is clear—they need to be much more strategic in how they tackle social determinants of health (SDoH). They need to have a new look at broader industry partnerships and programs, as well as advanced technology solutions.