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Jun 2016 - IDC PlanScape - Doc # US41380616

IDC PlanScape: Value-Based Reimbursement Demands Payers Execute an Exchanges-Like Level of Effort

By: Jeff RivkinResearch Director, Payer IT Strategies

Table of Contents

IDC PlanScape Figure

Figure: IDC PlanScape: Value-Based Reimbursement

Executive Summary

Why Is Preparing for Value-Based Reimbursement Important?

Fee for Value Replacing Fee for Service as Standard

VBR Efforts Are Diverse and Need Focus

Medicare Has Official VBR Goals by EOY 2016 and 2018

Competitive Contracting Advantage Is Necessary

Medical Loss Ratio Puts Emphasis on Profit Margins Over Time

FFS Is Being Forced To Be Less Attractive to Providers

Stem the Tide of Disintermediation

Employer Disintermediation

Provider Disintermediation

What Is Preparing for Value-Based Reimbursement?

It Means Deciding What Methodologies You Want to Support

It Means Adjusting Claims and Rating Workflows and Systems with Embedded or Parallel Reimbursement Logic

It Means Preparing Middle-Office and Back-Office Workflows and Systems

Who Are the Key Stakeholders?

Product Management

Plan Management

Contract Management

Appeals/Customer Service



Care Coordination/Medical Management

Provider Network Management

Provider Relations

How Can My Organization Take Advantage of Preparing for Value-Based Reimbursement?

Reconsider Your Mental Health Carve-Out Strategy

Execute Creative Product Design via Automated Product Configuration

Enable New Affiliations via an Enhanced Provider System of Record

Enable Contract Management Agile Processes and Software

Ensure a Flexible Tie from Product to Network Definitions

Enable a Flexible Environment for Quoting and Rating Engines

Define What Episodes of Care Supported

Implement Episode Modeling Software

Implement or Tweak Episode Recognition (Grouper) Software

Implement Episode Reconciliation Procedures and Software

Invest in Ubiquitous Workflow

Foresee Significant Reconciliation Workflow

Like Everywhere, Use Analytics

Identify Software to Parse Claims and Encounters, and Route Them to VBR and FFS Engines Simultaneously

Enhance Member 360/CRM Databases

Consider Additional Financial Subledger/Traceability Software

Rethink Approaches to Quality Measurement past HEDIS and STAR Ratings

Essential Guidance

Related Research

Appendix — Alternative Payment Model Methodologies

Pay for Performance

Bundled Payment/Episode of Care



Bundled Contracting

Primary Care Medical Home

Shared Savings (One-Sided Risk)

Shared Risk

Capitation Full Risk


Related Links