Understanding Value-Based Care Challenges
Prior Authorization and Data Interoperability Issues
Payers and providers have experienced turbulent relationships throughout healthcare history, even before the Affordable Care Act reshaped the industry landscape. Today’s healthcare environment presents unprecedented challenges as prior authorization requirements and data interoperability demands intensify. Combined with increasing patient volumes and extensive clinical documentation needs, both payers and providers operate under immense pressure to deliver quality care while managing administrative complexity.
Administrative Burden on Healthcare Systems
The modern healthcare ecosystem struggles with fragmented systems that create significant administrative overhead. Healthcare professionals must navigate multiple disparate platforms to access comprehensive patient information, leading to inefficiencies that drain valuable time and resources. This administrative burden directly impacts the quality of patient care and the ability of providers to focus on clinical decision-making rather than paperwork.
The Foundation of Value-Based Care
Patient Outcomes Over Service Volume
Value-based care (VBC) represents a transformative alternative to traditional fee-for-service models by fundamentally changing how healthcare providers approach patient treatment. Rather than emphasizing service quantity, VBC incentivizes providers to deliver proactive, preventive care that improves long-term patient health outcomes. This model requires providers to accept greater financial risk while focusing on quality metrics and measurable health improvements.
Under VBC arrangements, healthcare providers receive reimbursement based on patient health outcomes and care quality rather than the volume of services delivered. This shift encourages more strategic, patient-centered approaches to healthcare delivery. The ultimate goal focuses on reducing hospital readmissions, preventing disease progression, and controlling escalating healthcare costs through outcome-based reimbursement structures.
Holistic Patient Data Requirements
For VBC to succeed, providers must maintain comprehensive views of their patients’ complete health histories. This holistic perspective enables better patient management, more accurate diagnoses, and more effective treatment plans. However, achieving this comprehensive view often requires accessing multiple disconnected systems, creating significant workflow challenges and administrative burdens that can undermine VBC effectiveness.
Although fee-for-service models continue dominating the healthcare industry, value-based care has gained substantial traction in mainstream healthcare delivery. When implemented effectively, VBC encourages patients to become more active participants in their healthcare journey, improving adherence to treatment plans and preventive care recommendations.
Breaking Down Collaboration Barriers
Disconnected Systems and Incomplete Data
In a recent webinar, Amanda Banister, Senior Manager of Provider Performance and Tech Utilization at Veradigm, shared critical insights about advancing VBC implementation. She emphasized that collaboration between providers and payers represents the cornerstone of successful value-based care programs.
“Value-based care isn’t just a policy shift. It’s transformation and how we deliver, measure, and reward care. But transformation requires connection. Too often payers and providers are working from disconnected systems, incomplete data, and misaligned incentives — and patients caught in between experience fragmented and reactive care,” Banister explained.
Healthcare data often exists in silos or arrives with delays that diminish its clinical value. Without proper context, this fragmented information prevents both providers and payers from understanding the complete patient picture necessary for effective care coordination.
Misaligned Incentives Between Stakeholders
Misaligned incentives create significant obstacles for VBC adoption. Providers face expectations to assume greater financial risk without corresponding operational and financial support systems. Clinicians must simultaneously close care gaps, manage quality metrics, and document risk factors while navigating clunky portals and manual processes that reduce efficiency and increase frustration.
“Providers often feel like they’re being second-guessed by health plans, administratively burdened to gather important information about their patients for whom they need to make informed decisions and follow best practices. Payers often feel ignored when they deliver reports and data to providers without a response in a timely manner, if at all,” Banister explained.
Workflow Disruption and Provider Fatigue
Workflow disruption and provider fatigue pose serious challenges to VBC adoption and implementation. All stakeholders experience transparency gaps that hinder effective collaboration. Without clear communication channels and shared visibility, collaboration feels like oversight rather than genuine partnership. These communication breakdowns erode trust and prevent the cooperative relationships essential for VBC success.
Banister emphasized that successful VBC depends heavily on both payers’ and providers’ knowledge and willingness to collaborate effectively. “And let’s be real, that just isn’t easy,” she acknowledged candidly.
For payers, significant investments in quality improvement and risk adjustment programs depend on better data access, stronger provider engagement, and sophisticated tools supporting point-of-care decision-making.
EHRs as Collaboration Solutions
Real-Time Clinical and Payer Data
Electronic health record systems offer powerful solutions for bridging the divide between payers and providers. Banister highlighted how EHR vendors occupy a unique position with capabilities benefiting both stakeholder workflows.
“EHR vendors sit in a unique intersection with capabilities that can assist both payer and provider workflows. We’re seeing the evolution of native platforms that can make clinical and payer data actionable in real time. That’s a major shift from where we were even a few years ago, and it’s creating new possibilities for how we support both providers and payers,” she noted.
Closing Care Gaps Through Technology
For VBC success, providers must help patients close critical care gaps including chronic condition management, missed annual physicals, overdue immunizations, and preventive screenings. This requires enhanced partnerships where payers and providers share all relevant patient data seamlessly.
“We know that preventive screenings and early interventions can reduce downstream emergency room visits and in-patient stays,” Banister observed. “We also know that shared data reduces duplicative testing and unnecessary referrals.”
Embedding actionable patient care gap information directly into provider workflows enables real-time clinical decision support. Capturing real-world EHR data to inform care quality initiatives allows payers to drive collaboration, shared understanding, mutual accountability, and improved outcomes.
Best Practices for Payers
Setting Achievable Goals
Banister offered practical advice for payers seeking improved provider collaboration. “Don’t expect providers to do everything all at once. Deliver asks and goals that are attainable, scalable, measurable asks that are easy wins. Providers will get on board when they see how value-based care improves patient outcomes, not just cutting costs,” she urged.
Providing Real-Time Insights
Payers should provide high-quality data and real-time insights rather than complex spreadsheets. Effective tools help providers identify gaps, risks, and opportunities without overwhelming them with administrative work. Timely care gap alerts and comprehensive medication histories enable providers to escalate treatment plans before patient conditions deteriorate.
Payers possess visibility into longitudinal claims data, but this information only benefits providers when accessible at the point of care. Care gap alerts delivered while patients are in the office create optimal intervention opportunities because providers can address issues face-to-face immediately.
Creating Transparent Incentive Programs
Payers must make incentive structures crystal clear to providers. Transparent, achievable goals tied to shared savings or performance bonuses prove meaningful to healthcare organizations. “Support them, don’t micromanage them. Offer tools and guidance but let providers lead care decisions. The real bottom line with providers is when they feel heard and equipped and rewarded, they’re going to lean in,” Banister emphasized.
Moving Forward Together
Reducing Friction and Building Trust
Banister summarized the pathway toward successful payer-provider relationships: “First, we need to create less friction and more trust, meeting providers where they are and providing pathways to support their efforts.”
Ecosystem Thinking and Interoperability
The second critical element involves cultivating ecosystem thinking. Increased interoperability and provision of actionable, timely, accurate data to providers will drive the results payers require. When providers feel heard, equipped, and appropriately rewarded, they naturally embrace value-based care principles and actively participate in collaborative healthcare delivery models.
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