Aimee Rosewall-Godley

The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) released last January builds on previous initiatives to reduce administrative burdens for both Payers and Provider ... advancing EMR interoperability within the prior authorization workflow through HL7® FHIR® transactions. Key Benefits Include ... - Improved decision-making and outcomes through real-time access to comprehensive patient records and CDSM. - Automation of requests directly from the ordering Physician platform. - Member / Patient empowerment through transparency and access to their health data. I’m excited about these advancements, witnessing improved efficiencies within HealthHelp's own operations. Let me know if you would like to continue the conversation. #HealthcareInnovation #Interoperability #PriorAuthorization #PatientCare #HealthTech

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So I asked ChatGPT: "what are the three main challenges that payers face when scaling up VBC contracts?" Pretty impressed by the reply! --- Value-based care (VBC) contracts offer potential benefits in improving patient outcomes while controlling costs, but scaling them up presents several challenges for payers: 1. **Data Infrastructure and Analytics**: VBC relies heavily on data analysis to measure outcomes and determine payments. Implementing robust data infrastructure capable of collecting, processing, and analyzing large volumes of clinical and financial data is essential. However, many healthcare organizations struggle with interoperability issues, data silos, and data quality concerns. Scaling VBC requires investments in advanced analytics capabilities and interoperable systems to effectively track patient outcomes and ensure accurate reimbursement. 2. **Provider Engagement and Alignment**: Successful VBC implementation depends on strong collaboration and alignment between payers and providers. However, engaging providers and getting them to buy into new payment models can be challenging. Many providers are accustomed to fee-for-service reimbursement and may be hesitant to adopt new care delivery models that require changes to their workflows and financial practices. Payers must invest in provider education, support, and incentives to encourage participation in VBC programs. Additionally, aligning incentives between payers and providers is crucial to ensure that both parties are working toward the same goals of improving quality and reducing costs. 3. **Risk Management and Financial Sustainability**: Transitioning to VBC involves assuming more financial risk for patient outcomes and healthcare costs. Payers need to carefully assess and manage this risk to avoid financial losses. Balancing the risk-sharing arrangements in VBC contracts, setting appropriate benchmarks, and establishing mechanisms for risk adjustment are critical aspects of managing financial sustainability. Payers also need to develop strategies for monitoring and mitigating risks associated with fluctuations in patient populations, healthcare utilization patterns, and external factors such as regulatory changes and market dynamics. Successfully scaling up VBC contracts requires addressing these challenges through strategic investments in data infrastructure, provider engagement, and risk management strategies. Collaboration among stakeholders, innovation in payment models, and continuous evaluation and adaptation are essential for driving the widespread adoption of value-based care.

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eternalHealth is transforming how Medicare Advantage plans operate by challenging old norms with a data-driven, interconnected approach to delivering member care and partnering with providers. In this candid discussion, eternalHealth's CEO, Pooja Ika, shares how the organization's tech-first approach is improving access to care. https://lnkd.in/eYBmCt_a #MedicareAdvantage 

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#telemedicine, #Walmart Health Instead of viewing telemedicine as just a convenient, stand-alone option, we should integrate it into multi-channel care models that blend in-person with asynchronous (e.g., messaging, RPM) and synchronous (e.g., chat, phone, video) virtual care.

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