By Lynn Carroll

It takes a village. Moving toward value-based care (VBC) in the U.S. healthcare system requires engagement and cooperation from multiple players. Stakeholders include accountable care organizations, social service and community-based organizations, multiple payers, and a range of providers. Ideally, these groups and individuals work seamlessly together to create multiple policies and payment strategies inherent to VBC success.

When a village grows over time into a small city, the infrastructure must grow along with it; otherwise, major obstacles and issues arise. The same holds true with VBC collaborations – as they grow and become more complex, so too must the IT systems that support them.
Beyond just a greater number of stakeholders, VBC models require far more data generation and data exchanges to manage contracts than previous fee-for-service (FFS) ones. They also require more optimized data to meet various reporting requirements, improve collaboration, account for Social Determinants of Hhealth (SDoH), and address other factors relevant to optimizing care coordination.

VBC is no longer just on the U.S. government’s wish list. The Centers for Medicare & Medicaid Services (CMS) aims to have all Medicare beneficiaries using a VBC model by 2030. Provider participation in VBC has increased since first introduced by CMS in 2012, to the point that by 2022 most physicians, almost 60%, engaged in at least one payment model. This figure was up from 39% in 2019.

IT to help overcome inertia
However, despite the growing participation and a broad consensus on advantages – including a greater emphasis on integrated care, lower hospital readmission rates, and lower costs – adoption of VBC has not been as rapid or extensive as required for the desired impact.

Institutional inertia is partly to blame. The FFS payment model has been the primary method for claim submission and reimbursement for decades, and healthcare has been slow to switch one system for another. It does not help that healthcare is an enormous and highly regulated industry with so many stakeholders.

Many IT infrastructures cannot adequately support this emerging VBC ecosystem, as many payers are learning. With legacy IT built to handle simpler FFS and/or pay for performance models, these systems cannot manage complex VBC requirements. Instead, scalable and reliable cloud-based infrastructure is a viable solution.

A multi-tiered system
Although a simplification, it is easier to picture VBC networks as three stacked layers. The top layer is a complex hierarchy with payers and other funding sources. The middle layer features risk-bearing hospitals, ACOs, independent practice associations, direct primary care, and specialty carve-out organizations. Participating providers fortify the structure as the bottom layer.

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