In recent years, the U.S. healthcare industry has been steadily shifting to incorporate more alternative payment models that prioritize and reward care outcomes, reduced costs, and improved patient access. These alternative models—known generally as value-based care—aim to increase the quality of care patients receive, while simultaneously driving down costs.

The rise of value-based care is driven, in part, by the distressing legacy of the more common fee-for-service model—today, the U.S. spends more per capita on healthcare than any other developed country, while achieving the worst health outcomes among developed countries.¹

Charging payers and patients for services rendered, rather than care outcomes, has helped create this troublesome imbalance.

Thankfully, value-based care programs are growing in popularity. McKinsey estimates that the number of people covered under value-based care models will increase by 109% between 2022 and 2027, from roughly 43 million people to roughly 90 million people.² This rising trend should help improve care outcomes while driving healthcare costs down, a benefit to both patients and healthcare providers.

Practices interested in incorporating value-based care programs into their revenue models should be aware of certain revenue cycle management (RCM) complexities unique to these alternative models and consider how well suited their HIT tools are to help manage those complexities.

Let’s take a closer look at the RCM and healthcare IT considerations behind this emerging model.

Healthcare organizations that use mix of payment models feel more financially secure

Value-based care is a relatively new model, and many healthcare organizations are still evaluating if, and how, they’ll incorporate value-based programs into their business strategies. Some, like those that accept Medicare alongside insurance payers, may be delivering value-based care without thinking about it as such. Most are choosing to test the viability of these programs in a measured way. Today, there are relatively few practices using value-based care programs exclusively; instead, most are adding value-based programs alongside more traditional fee-for-service models.

This approach is showing positive returns: according to recent research , physicians using a mix of payment models feel that their practices are more financially secure. That’s good news: it means healthcare organizations have an opportunity to branch into value-based care and test its viability and diversify revenue streams, all without assuming too much financial risk in the short term.

Value-based care success hinges on effective use of an integrated healthcare IT platform

Data and connectivity are essential components in managing and monitoring value-based care programs and capturing maximum reimbursements. According to HFMA, “By embracing change and investing in technology that supports automated revenue cycle processes and advanced data analytics, providers will be better able to manage the intersection of VBC and revenue cycle management.”³

Automation isn’t the only consideration: utilizing a healthcare IT platform that integrates electronic health records and patient engagement capabilities alongside revenue cycle management tools and services is also important due to the unique reporting requirements for value-based care programs. For example, a particular value-based care program may require reporting on the quality and effectiveness of the care provided, the costs associated with the services provided, and specific patient engagement metrics, among others. A consolidated practice management platform should be able to report on all these requirements efficiently and accurately.

Interoperability is also key: a connected healthcare IT platform that can send and receive information with other platforms is crucial in order improve care coordination, a top goal of VBC.

Next, let’s look at the top technology-enabled capabilities healthcare organizations should leverage for revenue cycle success with value-based care programs.

Top 5 revenue cycle management considerations for value-based care success

Here are some of the most important technology-enabled revenue cycle management considerations for healthcare organizations looking to incorporate value-based care programs.

1. Accurate and complete clinical documentation

Proper documentation is crucial for value-based care reimbursement. Providers need to ensure that all relevant patient information, including diagnoses, procedures, and outcomes, are accurately and completely documented within electronic health records to support appropriate medical coding and billing.

While keeping up with clinical documentation can be burdensome, there are AI-enabled documentation tools available today that can help providers increase the accuracy and efficiency of documentation while also removing a large portion of the workload typically managed by physicians and clinical staff.

2. Integrated platforms for electronic health records and medical billing

Providers should utilize a healthcare IT platform that combines electronic health record (EHR) and billing capabilities into a single platform. This integration allows for seamless capture of clinical and financial data, ensuring accurate and complete coding and billing for value-based care services.

Some technology providers also offer revenue cycle management services for processes like billing, which can provide even better operational efficiency and accuracy.

3. Population health and risk management

Managing value-based care programs often involves risk stratification and population health management to identify high-risk patients and provide targeted interventions for patient-centered care.

The right platform, consolidating electronic health records and revenue cycle management capabilities, should support these efforts by facilitating the identification and tracking of high-risk patients and ensuring appropriate billing and reimbursement for the associated services.

4. Accurate and compliant medical coding

Accurate and compliant medical coding is essential for value-based care reimbursement. Providers should take special care to ensure that their coding practices align with the specific requirements of value-based care programs, such as Hierarchical Condition Category (HCC) coding for risk adjustment.

Similar to the closely related medical billing function, some technology providers offer services to take on much of the medical coding work, including providing expertise around evolving compliance issues related to value-based care contracts .

5. Quality reporting and performance monitoring

Organizations that want to leverage value-based care need a healthcare IT platform that offers robust quality reporting and performance monitoring capabilities. These capabilities enable practices to track and report on various quality metrics required for value-based care programs, such as MIPS, ACO, and PCMH. The platform should also provide real-time visibility into performance metrics, allowing practices to identify areas for improvement and optimize reimbursement.

It's also important to remember that payers have unique and evolving requirements for quality and performance, so look for a healthcare IT partner with both broad and in-depth experience with a variety of payers.

Leverage athenaOne^® to optimize revenue cycle management for value-based care

athenaOne^® is a comprehensive, integrated healthcare IT platform with robust capabilities around revenue cycle management, electronic health records, and patient engagement. The athenaOne platform and associated services enable healthcare organizations to thrive while operating under whatever mix of payment models suit their practice best, including value-based care programs. The platform is highly interoperable: athenaOne customers have access to more than 165,000 clinical integrations with labs, imaging centers, pharmacies, patient record sharing networks, and other entities.⁴

athenaOne value-based care capabilities

athenaOne is built with the capabilities needed to achieve success with value-based care programs, including:

• Innovative tools for clinical documentation to help you efficiently produce accurate and complete documentation
• Population health management reports to help you identify high-risk patients and provide targeted interventions
• Automation and services for accurate, compliant, and scalable medical coding, resulting in better rates of reimbursement
• Revenue cycle analytics and reporting to identify opportunities and optimize program performance
• Compliance and regulatory support to provide guidance on evolving regulatory requirements

The future of value-based care in the US

Many healthcare organizations are still in the early stages of incorporating value-based care programs into their businesses and operating models. These programs offer benefits to both providers and patients that may well be worth the effort required to get them established and successful.

A knowledgeable and experienced technology and industry partner is a must-have for organizations wanting to succeed with value-based care models. Consider a platform like athenaOne to provide the unique capabilities and expertise needed to find success with value-based care.

Read the articles below to learn more about how athenaOne helps healthcare organizations find great financial success.

1. The Commonwealth Fund, U.S. Health Care from a Global Perspective, 2022: Accelerating Spending, Worsening Outcomes, Jan. 2023; https://www.commonwealthfund.org/publications/issue-briefs/2023/jan/us-health-care-global-perspective-2022
2. McKinsey & Company, What to expect in US healthcare in 2024 and beyond, Jan. 2024; https://www.mckinsey.com/industries/healthcare/our-insights/what-to-expect-in-us-healthcare-in-2024-and-beyond
3. HFMA, Bridging the gap: Integrating value-based care into revenue cycle management, May 2024; https://www.hfma.org/revenue-cycle/bridging-the-gap-integrating-value-based-care-into-revenue-cycle-management/
4. Based on athenahealth data as of Jun. 2024