According to the most recent numbers from Centers for Medicare & Medicaid Services, healthcare spending represents 17.7% of the U.S. Gross Domestic Product, growing to $3.8 trillion in 2019. Americans spend more money per capita on healthcare than any other country in the world. However, as life expectancy is increasing across the globe, it has actually declined in the U.S. since 2014.
Healthcare costs are out of control, and value-based care is recognized as the most significant initiative that can turn things around. With the fee-for-service model, the healthcare system is waiting to treat people who get sick. With value-based care, the providers get paid for keeping patients healthy and avoid expensive encounters and hospitalizations.
The concept of value-based care is the opposite of how the U.S. healthcare system operates today. So naturally, there has been resistance by both health plans and providers. The fee-for-service model is so entrenched in care delivery that providers rely on a constant revenue flow when paid for treating patients. And while providers are interested in making patients healthy, proactively keeping patients healthy is an entirely different approach to care. The burden is on the provider to ensure the patient receives preventative treatment; this requires keeping up with people, making sure they’re proactive with check-ups and other services, and taking medications, among other things. It also means that providers must take on some of the risk that health plans have traditionally borne.
For successful value-based arrangements, health plans must provide actionable data and analytics to the providers. In order to hold a primary care physician (PCP) accountable for a patient’s health outcomes, the health plan must offer a comprehensive, 360-degree view of the patient and their claims and encounters.
For example, if a patient with diabetes goes for an annual eye check-up—which they need to do—their health plan must provide that data in an easy to consume way for the physician to know what kind of care the patient is receiving. It’s up to the health plan to provide the data that lets the PCP know everything about the patient’s condition and treatment. Without the data, the PCP will be disconnected from the actual maintenance or proactive steps a member needs to take to stay healthy, often resulting in costly treatment.
In a recent webinar, HealthEdge customer Eric Decker, SVP of Information Technology and CIO at Independent Health, shared that his organization has value-based arrangements with 100 percent of their primary care physicians. They understood that information sharing was critical to the success of these agreements. To effectively share data, they built capabilities available to the PCPs in their provider portal to communicate with the providers with scorecards that show how each physician is performing relative to their peers and view outstanding gaps in care.
If the entire healthcare system embraced value-based care, everyone would be working together to keep patients healthy. With value-based care, the quality of care and outcomes that come from preventative measures will keep costs down and, hopefully, cause life expectancy to climb back up.