How can health systems deliver the right care at the right cost in the right setting without overwhelming delivery and reimbursement systems with added administrative burdens?
The shift from volume to value-based care requires the deft combination of value-based delivery – enabled through actionable intelligence and new care delivery models—with value-based payment—enabled through select provider networks and new reimbursement models.
Essentially, providers and payers must operate across a transparent, administratively simple shared ecosystem.
This giant leap from today's volume-based world might appear impossible. But as providers take on greater accountability for cost and share more risk with payers, there is real urgency for change.
The good news: the technological capabilities needed to affect change are available today. What's missing is an effective bridge between today's volume-based systems, in which providers and payers communicate after the care decision (with the limited exception of pre-authorization), and a value-based system in which rich data and enhanced intelligence are automatically shared in real time to inform decision making.
Such a bridge can be built by using the current pre-authorization model as a foundation. Despite its limitations, the existing pre-authorization model can be used to enhance current core systems and investments and create a new form of utilization management (UM) that shifts the balance of interactions from post-care decision to pre-care decisions. This can be done using an exception-based approach that increases the value of the authorization interaction itself –transforming it into a practical form of decision support while avoiding the need to completely rebuild healthcare.
By using authorizations to drive communication around evidence-based practices and appropriate care at the point of care, we begin to bring value-based care delivery and, ultimately, payment together at the point when they provide the most value. Doing this will foster genuine collaboration between payers and providers, which can help ensure that quality care for value is delivered at the same time that administrative burdens are significantly reduced.
To read more, download the white paper: Rethinking Utilization Management