In recent years, healthcare has witnessed a transformative synergy between value-based care (VBC) and advancing technology to achieve the goals of The Triple Aim to lower costs, drive better quality, and achieve higher patient satisfaction. We are now in an era where providers can prioritize care quality and outcomes over care volume because we have seen that more care (incentivized by a broken fee-for-service system) doesn’t necessarily translate to better outcomes or satisfaction.
In a culture of proactive healthcare, patients’ well-being takes center stage. It might sound obvious, but it’s a profound reimagining of how we deliver the best care while reining in escalating costs. It’s also only possible with the investment and embrace of advanced technology which leads to consequential benefits. That includes Artificial Intelligence (AI) & Machine Learning (ML) for in-depth cost and quality insights, actionable care management and population health tools, and streamlined payment technology built for a value-based care world. The intersection of advanced technology and VBC creates an opportunity to forge a sustainable path where we can control costs without sacrificing great care.
The Migration to Value-Based Care
The traditional fee-for-service model has long dominated healthcare. But it incentivizes the wrong things by promoting more volume instead of better outcomes. The fee-for-service system’s limitations – disjointed care, escalating costs, and only treating ailments after they occur rather than averting them – is a driving force behind the shift toward VBC. And everyone with a stake in better healthcare must come along.
In addition to traditional payers, self-funded employers, healthcare providers and delivery organizations, large corporations like CVS and Walgreens are pursuing VBC initiatives. They are expanding far beyond retail pharmacy to offer primary care, home health, and other benefits in low-cost, convenient ways aimed at expanding access. Companies like Walmart and Amazon are engaged in primary care and other health initiatives, with Walmart recently announcing it is joining with UnitedHealth to improve care quality and lower costs.
The move toward VBC is not slowing down, it is accelerating across government, payers, providers, and self-funded employers. Now is the time to embrace VBC to realize the potential of integrated, aligned payment and care models. But it can only succeed when accompanied by a similar leap in technology that enables the activities necessary to take on risk. Fortunately, advanced technologies and end-to-end software platforms are enhancing VBC programs for all healthcare delivery organizations. These advancements drive better decision-making based on quantitative insights, and swift interventions to positively impact patient outcomes while enhancing efficiency, all while lowering the total cost of care.
Timely Interventions Lead to Enhanced Outcomes
The legacy U.S. healthcare system that relied on fee-for-service payment models, resulted in a care process which was completely backwards. Patients visited their doctor only after they got sick, rather than seeing them regularly to prevent illness and disease progression. Providers had little or no incentive to encourage preventive care because it was harder to get paid for these activities in a volume-based reimbursement system. Emphasizing early interventions for all patients, but especially those with costly chronic diseases, is at the heart of efforts to achieve better outcomes and a patient-centric medical system.
VBC empowers healthcare providers and primary care physicians to pivot from exclusively treating illnesses to championing overall patient well-being through preventive activities (and reimburses them accordingly for the time they spend on prevention). Technology makes this proactive approach even easier with tools to predict disease risk, spot unfavorable or harmful trends, segment patient populations, and create cohorts based on specific conditions, care gaps, or other care needs. Early interventions and more personalized care through regular check-ups and condition management minimize the risk of acute incidents and the corresponding need for costly emergency or specialized care.
Predictive Analytics for Chronic Disease Prevention
An alarming 37.3 million American adults live with diabetes, and another 96 million between ages 18-65 have prediabetes. Diabetes and its related complications are now the country’s seventh leading cause of death. While individuals can take preventive measures to reduce their chances of getting the chronic condition or having it worsen, providers can also play a role in prevention.
AI and ML tools can now predict the risk that a person has or will develop a disease, such as diabetes, with remarkable accuracy. When providers have this information at their fingertips, they can take action to intervene sooner and prevent or slow disease progression. Physicians can pinpoint at-risk individuals, significantly diminishing the dangers and costs linked to unmanaged diabetes.
New models have an 80% accuracy rate in predicting diabetes risk within one year. Similar models can predict the risk of heart disease (coronary artery disease and congestive heart failure), as well as chronic obstructive pulmonary disease (COPD). The models use advanced algorithms to spot undiagnosed cases or coding errors, then assign a proprietary risk score. Patients with a score over 50 are flagged as “likely” to have the condition or be at risk of developing it within a year.
The timely interventions these AI and ML models facilitate are not only good for patients – giving them an opportunity to minimize the impact of these chronic diseases on their future health and well-being – but are also good for healthcare delivery organizations trying to lower care costs and boost quality.
Fostering Economic Efficiency by Optimizing Place of Service
When COVID-19 hit in 2020, medical facilities and healthcare networks saw a dramatic shift in the place of service for many procedures and surgeries. Patients who were previously undergoing procedures at hospital inpatient facilities shifted to outpatient care or ambulatory surgical centers (ASCs). An analysis of claims history from a commercially insured population showed a decline of 7.33% in inpatient surgery utilization from 2019 to 2021. The change was spurred primarily by the lack of hospital capacity at the height of the COVID-19 pandemic, and patient fears about being admitted to hospitals where they could be exposed to the disease. But the trend continued into 2021 as many patients and facilities realized the benefits of finding lower-cost alternatives to hospital inpatient stays for appropriate procedures.
Comprehensive analytics tools can help organizations identify the procedures and patients best suited for ASCs or outpatient surgery. When combined with care management and care coordination software, organizations can take the next step to act on those insights, steering appropriate patients toward lower-cost alternatives. In addition to cost savings, patients often get the same (or better) quality care, a good outcome, and high levels of satisfaction – all key components of value-based care efforts. This is just one way technology can help optimize efficiency; the right analytics software can surface hundreds of insights to help organizations improve care and lower costs.
The Future of Healthcare Delivery
In the evolving healthcare landscape, the convergence of advanced technology and VBC marks a pivotal moment to place patient well-being at the forefront, leverage early interventions to manage disease effectively, usher in a proactive healthcare culture, and reimagine care delivery. Technology purpose-built for a value-based care future offers a promising avenue for patients and healthcare systems to tread a sustainable path toward enhanced outcomes and resource optimization. The marriage of this technology and the prioritization of VBC goals makes lower-cost, higher-quality, patient-centric care delivery our future – for the benefit of all constituents across the healthcare ecosystem.
David L. Morris
David Morris is EVP and Chief Commercial Officer at Cedar Gate Technologies.