Payers need to be focused on the development networks that are not just narrow, but offer both consumer choice and a shared value reimbursement.
Today's healthcare environment places a greater emphasis on cost effectiveness, higher quality, access, and engagement, all of which is challenging providers and payers to change their business models.
It's predicted there will be 75 million lives in alternative payment models by 2020, increasing the need for payers and providers to address value-based reimbursement models and tools sooner rather than later.
Payers and provider-centric organizations offering health insurance products directly to consumers need to think about providing better intelligence and decision support capabilities to support benefit plan selection and related care decisions, whether this be through private or public exchanges or brokers.
Payers currently have a wealth of information that could be made portable to consumers on their mobile devices and be easily uploaded to a health insurance exchange system. This information includes previous year's claims history, providers used, medications, diagnoses, and a current summary of benefits. Such portability of information could be used to better support the consumer's selection and use of health insurance benefits.
There is not a one-size-fits-all path for the design and implementation of VBR programs and methods between payer and provider organizations. There is a continuing need for industry leadership from payers and providers to explore these models and implement value-based models of risk sharing that lead to meaningful improvements in the effectiveness and efficiency of care. Consumers must be part of the discussion if these programs are to be successful.
In order to make newer risk and savings related reimbursement arrangements work there needs to be changes on both the provider and payer sides.
Providers must understand and be willing to accept these arrangements, be open to sharing information with payers, and be committed to making the changes work. Providers need to have appropriate and sufficient motivation to change the care delivery models and payers need to collaboratively address this early in the process.
Payers need to be focused on the development of real--not just narrow--network arrangements to accommodate consumer choice and a shared reimbursement arrangement.
Managing risk requires accurate risk adjustment tools and ICD-10 may not be the best way to get there. There are many prospective attribution models but these will not be successful if a patient seeks care outside the area but still remains in the risk pool, such as the case with consumers who split their time between two or more geographical areas.
There is a real need for a combined track of the best features of both prospective and retrospective attribution models and this is where the next generation of predictive analytics can address these needs. Providers face the challenge of understanding exactly where the "leakage" is in terms of costs of care and/or consumers going outside the network. They also need to understand the impact and need for appropriate and necessary documentation, particularly where related to CMS' five star and other quality rating programs.
Deanne Primozic Kasim is research director of payer health IT at IDC Health Insights.