Shift from
Volume to Value

Health plans and providers are moving beyond analytics-driven pilots to full-scale operational value-based reimbursement (VBR) programs. Critical to this shift, is the alignment of financial and clinical data, administrative and contract automation, as well as transparency to control costs.

35% of all reimbursement will be value-based in the next 36 months1

MSSP programs to grow to 7.2 million lives in 20152

Over 50% of VBR contracts in the next 36 months will have downside risk3

Our goal is to have 85% of all Medicare fee-for-service payments tied to quality or value by 2016, and 90% by 2018.

Secretary of Health and Human Services
Source: NEJM

Identify savings opportunities and design outcomes-based programs

Automate the administration of value-based contracts and programs

Enable proactive transparency and tooling to drive provider adoption

Decision support to market new ACO products to employers to improve competitive differentiation

Identify savings opportunities and potential revenue risks

Adapt to VBR programs from multiple payers without increasing administrative burden

Deliver timely and accurate insights into accounts receivable from VBR programs

Identify network leakage

Key Implementation Capabilities

Pre-Contracting
Post-Contracting

Stratify at-risk populations assigned to providers. Identify partners with requisite quality, skills and patient access. Assess claims history to identify past payment trends.

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Develop baseline budgets and incentives to reward successful population health management partnerships. Identify metrics and measures that correlate to quality and cost control. Identify incentives and payment terms.

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Access an “integrated member record” that combine administrative, financial and clinical data for sharing complete, longitudinal views of patient care.

Learn how Edifecs Population Dimensions can help.

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Access to shared workflows across care teams to increase efficiency and improve care coordination.

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Configure thresholds for early detection of high risk patients and populations. Focus care management actions on patients with the highest opportunity for impact.

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Gather insights to detect changes in morbidity, health risk, patient behavior and compliance to protocols

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Match reported encounters, claims and payments to expected quality outcomes.  Identify partners and populations at risk that could impact risk sharing/gain sharing payments.

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Ensure partners receive quality and program payments according to contract terms.  Apportion shared savings across the care community.

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Volume to Value Maturity Model

Have you been successful scaling your value-based programs that reduces costs and improves service across your populations?

Our experts can help.

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  • CS

    Case Study

    Lessons Learned from the Road to Value and Savings

    An ambitious regional Blue Cross Blue Shield plan needed to embark on a major multi-component strategic initiative. This initiative consisted of achieving specific medical loss and administrative loss ratio goals—as well as compliance with new market laws.

    View Case Study

  • WB

    Webinar

    A Clear Path Forward: Paving the Way to Value-Based Reimbursement

    In today’s healthcare industry, both payers and providers are experimenting with strategies to adopt value-based reimbursement (VBR), such as Shared Savings, Episodes of Care, and Pay-For-Performance. These policies fundamentally redefine the boundaries and roles of health plans, providers and members.

    View Webinar

  • WB

    Webinar

    A Clear Path Forward: Paving the Way to Value-Based Partnership

    Value-based reimbursement methodologies, like Bundled Payments and Shared Savings, are taking a firm hold on the managed care and commercial markets. If these initiatives are to deliver on the “increased quality with lower costs” promise, then new types of partnerships must evolve between health plans, providers, members and employer groups.

    View Webinar

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1. New Value-Based Reimbursement Models to Eclipse Fee-for-Service by 2020 Source: Healthcare Informatics 2. IDC Reveals Health Insights Predictions for 2015 Source: Business wire


3. Centers for Medicare & Medicaid Services Source: CMS


4. Evaluating Current Trends of Reimbursement Models and Contracting with ACOs pg.9 Source: CBINET