CMS is pushing providers to shift to value-based care delivery and payment models through rewards and penalties based on performance. 90% of payers and 81% of hospitals now offer a mix of fee-for-service and other reimbursement models and by 2020 it is anticipated that two-thirds of payment will be based on complex reimbursement models with underlying value measures.
These new payment models leave providers with a higher degree of risk burden for patient care and the need to drive greater patient engagement. To succeed in this new risk-taking business, providers must focus on population health initiatives in order to understand their populations based on cost and quality and also be able to forecast the risk of high cost and high levels of care amongst the patients they serve.
In order to stay financially viable in the shared savings scenario, risk-taking businesses need to have transparency into where the greatest opportunity for impact lies related to over- utilization of resources, disease management and cost containment, all while maintaining high quality of patient care.
- Increasing complex populations (chronic condition management)
- Ensuring accurate payments from payers
- Meeting quality requirements and closing care gaps
- Low patient engagement
- Value-based care and contract performance
- Reducing care variation between providers
- Achieving population health management by understanding and stratifying patients through the lens of cost and quality, risk, and utilization measures
- Accurate documentation of diagnosis codes used in risk adjustment and quality measures.