How Value-Based Care Platforms Are Streamlining Health Coverage Options For Employers

Managing cost, quality, and risk

The recent global health crisis further illuminated the need for a long-overdue shift in healthcare delivery models in the U.S., with value-based care becoming increasingly recognized by private industry and the U.S. government as a future necessity. There is a tremendous need for a broad spectrum of tools to drive lower costs and deliver better patient outcomes. This approach is an essential change to the fee-for-service arrangements we have historically observed in the U.S. healthcare system. Fee-for-service arrangements layer costs on top of costs, driving significant inefficiency, thus rendering healthcare unnecessarily expensive. 
 

In addition, misdirected incentives may often negatively impact the quality of care. Ironically, in a fee-for-service environment, the level of waste often results in fewer resources to focus on patient quality of care. The vision of value-based care is to reduce costs and improve patient care while also driving value to employers, essentially helping them manage cost, quality, and risk.

The evolution is slowly becoming a revolution, with outdated solutions being replaced by new and more innovative platforms buttressed by deep and sophisticated healthcare performance intelligence. A recent study shows more than six in 10 employers are either using or actively considering the utilization of value-based care models. These models are most effective when partnered with Centers of Excellence (COE) programs. COE’s are designed for the needs of an employer population. They are formed through partnerships with specific providers, selected to perform specialized services because of their diagnostic expertise, appropriate care, outcomes, and favorable financial arrangements. 

Employers are incentivized financially with value-based care models through payment predictability and bundled pricing arrangements based on the specific needs of their employees. For example, when a Fortune 50 company partnered with a high-performance cardiovascular specialty network, creating a cardiovascular COE program, cost avoidance in the past three years amounted to nearly $12 million, with spend per cardiac care 25 percent lower than traditional health plans in the market.  

Savings for employers and employees are imperative to the future health of our society. Simply put, the U.S. healthcare system is at risk of failure if costs keep increasing at their historical rates. Healthcare spending in the U.S. has increased from 5 percent of the nation’s total economy in 1960 to an extraordinarily burdensome 18 percent in 2020 and now totals $3.8 trillion annually. As these costs continue to spiral uncontrollably upward, the need for value-based care continues to amplify out of necessity. More than ever before, employers are searching for alternative payment structures and care delivery models. Employers need new ideas.

Value-based models provide an attractive, game-changing benefit for employees while creating predictability for employers and providers who also recognize the benefits. The key concept here is that value-based care doesn’t shift cost from one part of the healthcare food chain to the other; value-based care generates value across the food chain. Providers are paid based on the quality of services rendered to the patient and the associated health outcomes. There are more significant incentives to provide quality, patient-centric care than a fee-for-service model in which providers are paid for each service separately and rewarded for sick care versus keeping patients well. 

A value-based care approach also allows the provider to take a more comprehensive approach because they can focus on the overall care needs of the patient, from mental health services to physical ailments. As a result, physicians are incentivized to provide optimal and preventative care, with one important aspect being the avoidance of unnecessary and sometimes, catastrophic patient healthcare costs.

Achieving Excellence

The most beneficial and qualitative value-based care models are paired with COE’s designed to identify providers that perform the specialized services needed. COEs can be selected based on the specific trends and health attributes of a particular workforce. In the cardiovascular COE example above, cardiology was chosen because the population was at higher-than-average risk for heart disease and heart attacks, which often necessitate some of the most expensive procedures in medicine.  

Preventative outcome-based care helps preserve the health of valued employees and thus the health of the employer. Getting ahead of some of the most dangerous conditions through a custom COE is a critical component of strategic thinking in employee healthcare management. Today, value-based COEs take the guesswork out of choosing the best-specialized providers by filtering the most suitable physicians for an employer based on the provider’s diagnostic expertise, accuracy in billing, and history of care performance.

COEs also tackle the financial negotiations with providers and payers when dealing with low-volume, high-cost procedures employees need. Additionally, COEs handle the complexities of claims administration, enabling employers to focus on their actual business priorities.

As companies and channel intermediaries work together to provide quality and efficient care, many turns to value-based care platforms in conjunction with COE solutions to streamline the process further. These technology platforms supply employers with quality metrics, analytics, and insights on providers, bundle fee-for-service claims and provide employers with precise data to reduce the potential for insurance fraud.  

Below are additional ways a value-based care solution helps HR and employee benefits teams as they embark on their journey through value-based care:
 

• Streamline workflows and automate the process of handling agreed-upon payment arrangements with care providers.
• Help organizations with established health programs meet their goals to track overall employee health improvements resulting from enhanced care quality.
• Provide intermediaries and employers with the technical capabilities, pricing structure, and data interpretation when determining the best insurance plan. 
• Provide the necessary tools for report-sharing with payers and providers.
• Streamline the complex processes of health coverage handlings by leveraging analytics that helps intermediaries and employers measure, predict, and reduce healthcare spending.
• Provide assistance from concierge services and further education to an employer's benefit-eligible population to assist with making informed decisions about the highest quality provider/COE's and the cost-share benefits to the employee/dependent.

As the nation moves into the next phase of the pandemic's impact on healthcare, company leaders and HR managers are increasingly adopting value-based care models. Through partnerships with COE’s, employers can offer their much-essential employees next-level benefits aligned with their population’s greatest needs.

By focusing on the most costly and dangerous conditions, employers can be confident their teams are healthier due to better care in an adequately incentivized environment, to the benefit of the employee and the employer. 

David B. Snow, Jr. is the Chairman and CEO at Cedar Gate Technologies. Visit www.cedargate.com  Connect David B. Snow, Jr. Follow @CedarGateTech