Value-based Care Models: Alignment Across Payers and Providers

Speaking of healthcare, the payment protocols are broken. Doctors get paid more for doing more procedures. Insurance companies pay more when doctors do more procedures. Nobody gets rewarded for keeping patients healthy. 

Value-based care models change this approach by paying doctors based on patient outcomes rather than the number of services they provide. When patients stay healthy, care providers make money. When patients get sicker, they lose it. Simple concept yet hard to execute.

What are Value-Based Care Models?

Value-based care models pay healthcare providers based on patient results. Good patient outcomes equal higher payments. Poor outcomes or wasteful spending equal lower payments or penalties.

Three main types exist:

• Capitation pays doctors a set amount per patient per month, regardless of services provided. 
• Bundled payments cover entire treatments like knee surgery, including all related care.
• Shared savings programs let providers keep part of any money they save compared to conventional costs.

How Do Value-Based Contracts Create Payer-Provider Alignment?

Value-based contracts make insurance companies and healthcare providers want the same outcome, i.e., healthy patients at reasonable costs. Both sides lose money when patients end up in expensive emergency rooms or need costly specialist care.

Alignment happens through:

• Splitting cost savings between insurance companies and providers
• Bonus payments when providers meet quality targets
• Financial penalties when patient outcomes are poor
• Extra payments for preventive care programs
• Funding for care coordination teams

Doctors stop fighting insurance companies over claim approvals. Instead, they work together to identify sick patients early and keep them out of hospitals.

Role ACOs Play in Value-Based Care Implementation

Accountable Care Organizations group doctors, hospitals, and specialists together to care for specific patient populations. The value-based care model for ACOs makes the entire group responsible for patient health and costs.

ACOs coordinate all patient care from routine checkups to specialist visits to hospital stays. When they keep costs below target amounts, the ACO keeps some of the savings. They use this money to pay participating doctors and fund disease management programs.

How Technology Platforms Support VBC Alignment?

Value-based care requires tracking patient outcomes across multiple doctors, hospitals, and insurance companies. Technology platforms gather data from medical records, insurance claims, and quality reports to calculate provider performance.

Platforms must handle:

• Medical record data from all participating providers
• Insurance claims and payment information
• Quality metrics and patient outcome tracking
• Provider performance reports and payment calculations
• Patient communication tools for treatment compliance

Without good technology, providers cannot track their performance or receive accurate payments. Manual data collection leads to errors and disputes.

Challenges That Prevent Effective Payer-Provider Alignment

Each insurance company measures quality differently. Providers cannot optimize performance across multiple contracts with conflicting requirements. Healthcare computer systems rarely communicate with each other effectively.

Major obstacles include:

• Different quality measures for each insurance contract
• Incompatible computer systems between payers and providers
• Insufficient funding for care management infrastructure
• Provider's fear of losing money on sick patients
• Complex regulations vary by state and insurance type

How Can Healthcare Organizations Measure Value-Based Care Success?

Measurement focuses on patient populations rather than individual visits. Organizations track clinical outcomes, costs, and patient satisfaction across all patients in their value-based contracts.

Key metrics include:

• Hospital readmission rates and preventable complications
• Patient satisfaction scores and appointment accessibility
• Total healthcare spending per patient, including all services
• Care team coordination effectiveness
• Chronic disease management results

Real-time measurement allows care teams to adjust their approach throughout the contract period. Without continuous feedback, problems go undetected until contract renewal.

Want A Value-Based Care Platform That Works?

Persivia builds platforms that connect payers, providers, and patients through shared data and coordinated workflows. Healthcare organizations use our systems to track outcomes, manage contracts, and succeed financially under value-based payments.

Persivia handles the complex data integration and performance tracking that value-based care demands. Our platforms work with existing healthcare systems while adding the capabilities needed for contract success.

Learn More.