Friday, May 22, 2015

Business Drivers and Market Forces for Healthcare Payors

I was recently, working on a business case, so, by popular demand, I am presenting "Business Drivers and Market Forces for Healthcare Payors"

A. Transition from Volume to Value (V2V) based reimbursement system

  1. Payers should not require primary providers to meet rigid certification or accreditation standards in order to participate in improved payment systems (such as ACO models) that improve outcomes or reduce costs
  2. Payers should phase in changes to support the changes in primary care
  3. Payers should make bundled payments to provider organizations and partnerships that demonstrate the capacity and expertise to manage the full episode of care and associated patients
  4. Payers, providers, regional collaborators and other organizations should take steps to facilitate the transition of bundled payments, including public reporting about the total cost of care, providing technical assistance to providers, and making transitional changes to payment systems
  5. Pilot projects for new payment systems should be designed to gain experience with care changes that will both improve quality and reduce or control costs

B. Bring the Individual and Family plans for specific markets under the volume to value structure

  1. Such as
  2. State Exchanges 

C. Evolving patient needs require localized and flexible provider-networks / products

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