The concept of value-based care (VBC) isn’t new — but the industry’s journey to achieve it is far from over. 

After two decades, healthcare is still working to find a better way to reward clinicians for the quality and efficiency of the care they provide rather than for the volume of patients treated. 

Payers are uniquely positioned to drive value-based care

Healthcare payers can play a significant role in helping providers deliver better patient outcomes as they have a unique combination of financial resources, data, and influence over payment models to make them well-suited to drive value-based care initiatives. Their focus on managing risk and controlling costs aligns with the goals of delivering high-quality, cost-effective care to patients, making them central players in the transition to value-based care models. 

The Centers for Medicare and Medicaid Services (CMS) has been at the forefront of value-based care, aiming to move every Medicare fee-for-service beneficiary and most Medicaid beneficiaries to care relationships with accountability for quality and total cost of care by 2030. Similarly, the largest commercial health insurers are investing in value-based programs to lower care costs and improve population health. 

Collaboration between health plans and healthcare providers is crucial in achieving better outcomes. Payers can provide the data, resources, payment structures, and incentives needed to drive quality improvement and ensure patients receive the right care at the right time. These strategies aim to align the interests of payers and providers to improve patient outcomes while controlling costs.  

Data sharing and analytics to drive VBC success 

Payers have access to vast amounts of data on patient care and outcomes. Sharing relevant patient data and performance information with providers can help them identify trends, gaps in care, and opportunities for improvement. Further, health insurers can provide predictive analytics to help providers identify high-risk patients, allowing for early interventions and personalized care plans.

In addition to patient outcomes data, payers can provide performance analytics to help clinicians understand their performance compared to benchmarks and national standards. They can also facilitate collaborations among providers in their network to share best practices and learn from each other’s experiences. 

Providing timely and precise feedback to providers about their performance can help build trust in value-based partnerships and give actionable insights for improvement. With the right data in hand, healthcare providers can understand trends in care outcomes, cost, and quality, make more informed decisions for their patients, and drive value-based programs forward. 

Resources to support providers in VBC 

Health insurers can provide a range of resources to healthcare providers to support value-based care initiatives. 

For example, payers can offer training and education opportunities to help providers understand value-based care models, quality improvement strategies, and care coordination techniques. 

Using their vast datasets, health plans can also help develop evidence-based clinical guidelines and best practices to support providers moving toward value. Providers can use these guidelines to standardize care and improve outcomes.

Payment structures and incentives

Payers control a significant portion of healthcare spending. By adjusting payment models and reimbursement strategies, they can encourage healthcare providers to focus on value (improved quality and cost-effectiveness) rather than volume (the number of services provided).

Many payers are adapting their reimbursement policies to support lower-cost services such as telehealth. By supporting virtual care, payers can expand access to care for members, leading to better patient engagement and outcomes, reducing physician burnout, and lowering costs. 

Health plans can offer financial incentives in the form of new payment models, quality bonuses, and shared savings programs to providers who consistently achieve high-quality outcomes and demonstrate cost-effective care. While incentives can motivate providers to focus on better outcomes, not all incentive programs are created equal. 

Recent payment innovations are looking outside of traditional value-based payment models to accommodate providers who may not be ready or properly resourced to take on risk. For example, through programs like Clarify Advance, health plans can achieve meaningful reductions in medical spend by directing members to more affordable, higher-quality specialists and sites of care without the hassle of value-based contracts. 

Conclusion 

Health plans can play a significant role in helping healthcare providers deliver better outcomes for their patients. By offering the right resources, data, and support, health insurers can empower healthcare providers to effectively transition to value-based care models, improve patient outcomes, and enhance the overall quality of care while controlling costs. We’re seeing exciting innovations across the industry that are driving value-based outcomes outside of traditional value-based structures in the form of new incentive models, reimbursement strategies, and data exchange.