The evolving landscape of value-based care (VBC) in 2024 is witnessing a dynamic shift, driven by nuanced changes that hold the promise of transforming healthcare delivery, quality assessment, and reimbursement methodologies. Here are the key trends that will need to be top of mind for provider organizations that are transitioning to VBC, or looking to improve their performance under value-based contracts.
V28 transition: Redefining risk adjustment and reimbursement models
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The phased implementation of the V28 model marks a significant departure from V24 in Medicare Advantage (MA) plans, signaling a recalibration in risk adjustment methodologies, with some codes down-weighted and others removed entirely, thus impacting reimbursement models. Providers need to recalibrate their systems and workflows to align with the updated criteria for risk scores and be on top of their documentation in order to weather the change.
HEDIS scores and star ratings: A balancing act amidst evolving NCQA benchmarks
HEDIS scores and Star ratings, critical yardsticks for assessing healthcare quality, are experiencing a downward trend. This is chiefly due to the National Committee for Quality Assurance’s (NCQA) stringent quality benchmarks, including the implementation of the Tukey outlier deletion method which makes it more difficult to earn and maintain four and five-star ratings, as well as other factors such as declining CAHPS patient experience scores. The evolving criteria seek to elevate standards, pushing healthcare providers and plans to pivot towards more patient-centric, outcome-driven care delivery models. Failure to adapt will mean a significant financial loss for plans because of lower-quality bonus payments. This requires a concerted effort to refine preventive care initiatives, chronic disease management strategies, and patient engagement programs to meet the evolving benchmarks.
Social determinants of health: Driving holistic patient-centric care
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2024 will see an amplified focus on Social Determinants of Health (SDoH), acknowledging their profound impact on health outcomes. This new direction, spearheaded by the U.S. government in the form of the White House’s new SDoH strategic playbook, underscores the critical role of SDoH in shaping health outcomes. The playbook aims to integrate SDoH into the fabric of national healthcare policy, transcending traditional clinical care boundaries. The goal is to create a healthcare ecosystem that is not only responsive but also proactive in addressing the social determinants that significantly influence patient health outcomes.
The Centers for Medicare & Medicaid Services (CMS), in response to this policy shift, are adapting their initiatives to prioritize SDoH factors. This includes developing and implementing strategies that extend care beyond the clinical setting to encompass a broader range of social needs.
Healthcare organizations are also expected to intensify their focus on SDoH. This involves a comprehensive approach that includes leveraging advanced data analytics to identify and support vulnerable populations more effectively. By recognizing and addressing social and economic factors such as housing instability, food insecurity, and transportation access, healthcare providers can offer more holistic, patient-centric care.
Specialty ACOs: Pioneering specialized care models in the VBC space
The emergence of specialty Accountable Care Organizations (ACOs), particularly in fields like nephrology and cardiology, marks a significant trend in healthcare. These specialty ACOs concentrate on delivering highly specialized care that not only enhances patient outcomes but also reduces overall costs. This approach enables specialists to actively participate in value-based care models, offering a structured pathway to integrate their expertise into broader healthcare delivery systems.
Importantly, specialty ACOs cater to patients who primarily rely on specialist care rather than primary care physicians. This model shifts the responsibility to specialists and their teams to take a more central role in managing the patient’s overall healthcare, akin to being the ‘quarterback’ of patient care. This shift is crucial for patients who might otherwise miss out on comprehensive care coordination.
Moreover, specialty ACOs are instrumental in fostering continuity of care. By promoting collaboration among specialists, PCPs, and health plans, they ensure a more unified approach to patient care. This collaborative effort is key to achieving better health outcomes nationwide, as it encourages providers across various regions to work together more effectively. The result is a healthcare system that is more responsive, efficient, and patient-centered, reflecting the evolving dynamics of value-based care.
Tech integration: Catalyzing efficiency and precision in care delivery
The integration of technology into health plans and clinical workflows will continue to gain momentum in 2024, in an effort to deliver more precise and timely interventions at the point of care. Advanced analytics, interoperable electronic health records (EHRs), telehealth solutions, and especially artificial intelligence (AI) tools are revolutionizing care coordination, decision-making, and predictive analytics. The advent of large language models and generative AI technology will have a profound impact going forward but will require organizations to be fastidious when choosing the right solutions for them. AI tools that enhance clinicians’ abilities without attempting to replace them, and are built to ensure their trust, will rise up. These tools will empower providers to glean actionable insights, including suggestions for suspected conditions and care gap alerts. They will help optimize resource utilization, and personalize patient care pathways, ultimately enhancing outcomes and patient satisfaction.
As the healthcare landscape evolves, these transformative trends in value-based care underscore the imperative for adaptability, innovation, and collaboration across stakeholders. Embracing these trends presents an opportunity for healthcare organizations to refine care models, optimize resource allocation, and ultimately, improve patient outcomes while navigating the complexities of an ever-evolving healthcare ecosystem.
Photo: doyata, Getty Images
Dana L. McCalley, MBA is the VP of Value-Based Care at Navina. She has more than 15 years of experience in value-based care and population health, leading large high-performing teams and optimizing workflows to drive outcomes. Before joining Navina, Dana was the Director of Quality and Risk Adjustment at Honest Medical Group. Prior to that, she was the Director of Risk Adjustment & Quality at Millennium Physician Group (MPG) for nearly a decade, where she focused on simplifying workflows for the 700+ providers across the organization. Her efforts led to over $159 million dollars in CMS ACO Shared Savings throughout her tenure. Dana received her Bachelors of Psychology from the University of South Florida and her Masters of Business Administration from Liberty University.
