Everyone is worried about the rising cost of healthcare. According to the Centers for Disease Control and Prevention (CDC), 2019 healthcare spending in the United States topped $3.8 trillion. That’s nearly 18% of the gross domestic product (GDP), as projected by the Centers for Medicare & Medicaid Services (CMS) Office of the Actuary. Further, per capita national health expenditures were $11,582. Prior to the COVID-19 pandemic, the CDC had projected healthcare spending would continue to grow at a rate of 5.3% a year, reaching nearly $6.2 trillion by 2028.
While the industry itself is realizing that it’s not immune to market forces, we need a new model which states that the dollar allocation that the market is prepared to pay for healthcare should be driven by who provides the most value — with lower cost and better outcomes.
Fee vs. value-based cost models today
Fee-for-service is the traditional payment model where providers are reimbursed for every service they provide, regardless of outcome. This leads to fragmented care — poor communication between providers, duplication of services, inaccurate diagnoses and unnecessary tests or treatments — that result in higher costs.
The shift to value-based care is underway, emphasizing quality over quantity, and focusing on preventive care, coordinated care and chronic condition management with the goals of improving patient outcomes and reducing costs.
The value-based model places the payer, provider and patient on the same side of the table. Both payer and patient are driven by the goal of lower cost, while all three parties are motivated to achieve better outcomes and higher quality results.
Technologies and tools
With high costs still being one of the main challenges to improving healthcare, we are focused on helping our customers use technology to reduce avoidable costs for both medical and administrative expenses.
Automation services, for example, help solve complex challenges and let customers streamline administrative operations associated with their healthcare digital transition to value-based care, while improving their security posture. We are also helping with artificial intelligence (AI), wearables and tools for preventative medicine that are driving this shift toward consumer-driven healthcare.
- AI streamlines medical procedures, helps predict patient outcomes and automates data-driven decisions.
- Wearables can track patient health in real-time, and can help provide more accurate diagnosis and comprehensive treatment recommendations.
- Preventative medicine is growing in importance and focuses on identifying and addressing health issues before they become serious illnesses. These advances promise improvements in care and health outcomes for patients shortly.
There is a generally accepted equation for value in healthcare, which should be the goal for all modern patient outcomes. Simply put, the value equation (value = quality/cost) can be thought of as the primary directive for all of healthcare going forward. To get there, Medicare Advantage, Accountable Care Organizations (ACOs), and patient-centered medical homes (PCMHs) have been introduced.
- Medicare Advantage is a private alternative health insurance with additional benefits and services not found in traditional Medicare.
- ACOs are healthcare providers that are accountable for the cost and quality of care for a defined patient population.
- PCMHs place an emphasis on prevention and management of chronic conditions.
However, cost, lack of access to primary-care physicians, and inefficient communication between PCPs and specialists are hindering the shift to value-based care. In addition, there is an over-reliance on pharmaceutical solutions, instead of other preventative measures such as encouraging lifestyle changes (incorporating exercise and healthy diet), offering telemedicine services to provide more access to primary-care physicians and promoting preventative screenings and vaccinations.
Primary care organizations such as ChenMed are helping to lead the charge with a proactive, holistic and clinical model that focuses on lifestyle, behavioral, and social determinants of health, rather than only treating diagnoses with medications, procedures and referrals. This approach has the potential to reduce risk and improve outcomes for patients.
There’s also a renewed push for price transparency in healthcare, which refers to making the costs of medical services and procedures publicly available to patients before they are treated. UnitedHealthcare's cost estimator tool is a successful example. However, it’s still not widely available. And I expect that price transparency will take a while to establish.
AI is increasingly utilized
AI is becoming more widely used and offers the potential to improve outcomes and reduce costs through population health management and accurate diagnoses. A key factor for its success is the security and privacy of patient data, which can be ensured with the help of automation services such as robotic process automation. RPA can lower administrative costs and boost the quality of services.
As healthcare systems become more advanced, they will be more responsive patient needs and preferences. The shift toward personalized and value-based care will ultimately lead to better patient health outcomes and improved quality of life.
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About the Authors
VP, Office of the CTO - Healthcare & Life Sciences
Vinesh has spent over two decades implementing transaction and analytic workloads for healthcare organizations. Over the past five years, he has implemented leading edge, award winning cloud based data lakes, data analytics, ML and AI workloads on AWS and other public cloud platforms. He is an AWS certified Professional Cloud Architect. Prior to his time at Rackspace Technology, Vinesh served as the CIO & Head of Engineering for Lumeris and Essence Healthcare where he was responsible for defining and executing the technology vision for the organization's health plan, assuring high performance, scalability, reliability and consistency of all technology offerings across health systems, M&A Plans and population health platforms. Vinesh received a master’s in computer engineering from SUNY Binghamton and a bachelors in electrical engineering from Mumbai University. Outside of work, he loves to travel, play table tennis, and spend time with his wife and two kids.Read more about Vinesh Kolpe