Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid


New Study Examines Payment Model Best Practices

By Ryan Mcaskill

- This week, IDC Health Insights released a new report entitled “Best Practices in Payer Health Management Programs: The Evolution of Quality and Payment Models.” It examines the background, underlying challenges and current best practices being implemented by health management programs and the biggest takeaway is that traditional care delivery models are being rethought.

The initiatives enacted by the Centers for Medicare and Medicaid Services including pay-for-performance and value-based reimbursement approaches have forced a change in focus. According to the payers that were interviewed for the study, 51 percent of responding organizations planned a new investment in care and disease management applications this year. This shows that organizations have both acknowledged that a shift in operation is happening and have started to fund the needed systems to prevent falling behind the rest of the industry.

Organizations that are successful in their approach will do so through managing several challenges in order to implement a more comprehensive health management solution. This includes focusing on the most at risk patients, partnering with the right stakeholder groups in the new reimbursement models, and meaningful engagement and education of consumers.

Deanne Primozic Kasim, the research director for Payer Health IT Strategies at IDC Health Insights said in the report that payer and provider organizations need to think outside of the traditional business relationship and reimbursement paradigms in order to deliver effective and efficient health management programs.

“Forward-thinking leaders are realizing that a post-reform environment, combined with unsustainable costs of care, demands a more population-based approach to health management programs,” Kasim said. “These programs need to be supported by innovative IT applications that are meaningful and accessible to all related stakeholder groups.”

The report goes on to focus on several best practices that organizations of all sizes across the payer and purchasing landscape. They include:

• Assessment of medical conditions and cases to determine what reimbursement models make the most sense for specific conditions and providers.

• Integrated relationships with a coordinated team of providers of all types.

• IT applications that integrate payer and provider access to the shared information components of claims payment, health management programs and provider reimbursement.

• Integration and explanation of cost transparency initiatives into member care programs.

• Greater degree of education and support for participating provider organizations with emerging reimbursement and quality measurement models including face-to-face meetings between health program managers and providers.

There are also a number of capabilities that health management programs and supporting IT applications need to have in order to be up to speed with the changing landscape while meeting future challenges. These cover more broad features like real-time information sharing across all stakeholder groups through a secure portal and predictive modeling and risk stratification tool to more industry specific ones like consumer experience assessments and evidence-based clinical guidelines.


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