Value-Based Payment Models

  • November 15, 2018

    We’re all being asked to think differently about how healthcare is provided and it requires us to work together. These partnerships will be built on trust, shared data and analytics, as well as, a deep understanding of who the customer is and what they want. Premera is here to help support you to ensure success in value-based care.

    Payment models in healthcare are actively shifting from traditional fee-for-service payments to value-based care models. This change represents a huge shift and challenge for most healthcare organizations which have financial and care models built around fee-for-service (FFS) reimbursement.

    The goal of new value-based care models is to slow the rate of increase in total cost of care and ensure that care is being delivered in the right place, at the right time, and by the right caregivers. These goals are met by balancing quality, cost, and patient experience.

    There is a wide range of payment models which may include:

    • A regular monthly payment for coordinating patient care which is in addition to the regular fee-for-service payments.
    • An agreement between the provider and the insurance company to reduce the total cost of care while increasing quality. Any savings will be shared at the end of the year.
    • A bundled arrangement where the provider and insurance company agree to a set price for a specific diagnosis or procedure, such as knee pain or a knee replacement. If the provider comes in under the set price they make more money on the procedure. If the procedure is more expensive than the set price, the provider will not be reimbursed for the extra costs.

    Value-based care models are impacting care across the continuum. This includes primary care, specialty care, and hospitals.

    Examples of care models well suited for value-based care include:

    • Accountable Care Organizations (ACOs)
    • Patient Centered Medical Homes (PCMHs)

    To learn more about opportunities to establish a value-based contract with Premera, contact your provider network executive.

    This article is first in a series dedicated to understanding value-based healthcare.

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