Value-Based Care (VBC) is a healthcare model that ties healthcare providers’ compensation to the quality, equity, and cost of care they deliver. The model focuses on improving patient outcomes, such as health quality and satisfaction, while also promoting cost-effective care. Providers are incentivized to deliver better care by focusing on the overall health of patients, addressing preventive care, and coordinating treatment. This model contrasts with the traditional fee-for-service system, where providers are paid based on the volume of services delivered rather than patient outcomes.

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CMS Interoperability and Prior Authorization Final Rule Synopsis

The Centers for Medicare & Medicaid Services (CMS) changed its prior authorization rules to simplify and digitize the process, and to reduce the burden on each of the three legs in the healthcare delivery tripod: patients, providers, and payers.  In particular, CMS aims to reduce administration, simplify and accelerate the process, and introduce standardization across payers.

It is critically important for providers and especially payers to get ahead of these changes by assessing processes and the technology necessary to support the rules change and ensure compliance.

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Precision Medicine as key driver of next generation personalized health care

The term “Precision Medicine” refers to the tailoring of clinical and other health care-related interventions based upon an individual’s unique make-up and circumstances. While personalization of care has long been the underpinning of best practice medicine, personalized care and Precision Medicine are not exactly synonymous. Precision Medicine is an expanded approach that uses information about an individual’s biological, environmental, and lifestyle characteristics to guide decisions related to their medical and health management.

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Part 1: The Current Landscape

The remarkable growth in Medicare Advantage enrollment over the past twelve years is raising questions about both the cost and quality of that coverage as well as the ultimate impact on health equity and solvency of the traditional Medicare program.

This is the first in a series of articles to follow, providing insight into the current landscape (both in terms of Medicare Advantage performance and growth) to help lay the foundation for steps that plan sponsors and provider organizations can be taking to prepare for the future.

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Payment Integrity Evolution

Over the past decade, the healthcare industry has seen payment integrity evolve from an under-resourced operational niche to a strategic asset that is central to the overall management of medical expense. A paradigm shift is underway, wherein many payers are recognizing that the status quo will not suffice in a volatile, disruptive market where, among other things, technology is advancing rapidly. Many are at the initial stages of fully understanding and implementing elements of a comprehensive future vision for payment integrity efforts, which in addition to dedicated analytic staff, comprise a team committed to ideation and innovation. Vital measures to track and drive performance of Payment Integrity (PI) initiatives, including the use of industry benchmarks and annual goal setting are gaining traction.

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Guiding Principles: Payment Integrity as a Strategic Enterprise Solution

Today’s technology innovations and workforce challenges (need to drive toward greater efficiency) are prompting payers to take a closer look at payment integrity with an eye toward a more strategic framework. More and more payers are recognizing that the status quo will not suffice in a volatile, disruptive market where change is happening with increasing speed.

Over the past decade, the healthcare industry has seen payment integrity evolve from an under-resourced operational niche to a strategic asset that is central to the overall management of medical expense, in addition to efforts to improve quality of care and foster mutually satisfying provider relations. Let’s look at some guiding principles establishing Payment Integrity as a strategic asset.

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Current State of Healthcare Payment Integrity: Article 1

Understanding what healthcare payment integrity entails and why there is renewed interest

Payment integrity encompasses efforts on the part of payers and healthcare providers alike to navigate ongoing challenges relative to achieving accurate and efficient payment. Having a system of payment integrity processes in place is essential for ensuring financial accuracy, maintaining compliance with regulators, optimizing the overall healthcare delivery system, and removing administrative waste which can have a negative impact on patient care and quality outcomes.

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Harnessing the Value of Artificial Intelligence (AI):

Protecting healthcare data privacy and security

AI at its core encompasses taking advantage of the rich and diverse sources of information that individuals and health care providers amass across the continuum of health-related behaviors, interactions, and management. Being able to better leverage these stores of data to enable predictions of health risk and more proactive engagement to promote better health care outcomes via AI tools and applications offers great promise. With this comes a responsibility to safeguard and ensure responsible stewardship of sensitive information. This includes both the use of the data itself as well as the output, predictions and actions that ensue. 

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Process Improvement: It Takes Leadership

How process improvement is managed above and beyond what is done is a key ingredient for success and can make the difference between a well-executed improved process and one that fails to deliver demonstrative, sustainable results. 

Our view of process improvement success is less about the process and tools mechanics and more on sharing insights on the leadership of the process – what are the management principles that come into play when the goal is to identify, plan and execute a successful process improvement initiative?  

As a backdrop to help illustrate this perspective, we will leverage a recent successful process improvement engagement undertaken on behalf of one of our clients.  Let’s start there. 

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