White Papers

ACO REACH, a new payment model from the Centers for Medicare & Medicaid Services (CMS) will replace the current Global and Professional Direct Contracting (GPDC) model on January 1, 2023.

Existing provider network management solutions are often developed for a single purpose, cobbled together with a disjointed combination of homegrown and legacy IT. They have been supporting evolving organizational needs such as credentialing portal, provider data analysis, and more. However, this approach is not a long-term solution to provider network management needs and prevents payers from gaining an unbiased, unified view of provider performance. Relying on claims data alone is insufficient.

Pediatric health providers—including health systems, pediatric care organizations, and clinically integrated networks—are under increasing financial pressure as a result of the COVID-19 pandemic, a declining birth rate, and increased awareness of health inequities. When you consider the current shift toward value-based care models in healthcare, it's easy to see that pediatric providers will have to adapt and change to flourish in the future. Unlike care for adults, pediatric care strategies require more than just technological interventions to enhance efficiency. This white paper discusses a framework for a new pediatric population health management strategy.

Historically, payers have focused on financial risk while providers have dedicated themselves to improving patient health at the encounter level. Both have stayed in their respective silos with little incentive (or the technological ability) to coordinate efforts. However, the dynamic between payers and providers is changing, with recent legislation and the COVID-19 pandemic accelerating that change even further. As a result, health plans have a prime opportunity to adopt technologies that will bridge the gap and emerge as industry innovators.

Value-based contracts have served as the catalyst for improving data exchange. According to a recent Innovaccer survey, around 80% of respondents have at least piloted a value-based care program or taken more definitive steps toward rollout. As more payers and providers enter into these contracts, addressing data integration challenges becomes very important.

It’s estimated that every patient generates close to 80 megabytes of data annually—that’s a lot of potentially useful data. But many healthcare organizations lack the ability to collect all that data in one place and use it to keep patients healthy. In fact, Innovaccer analysts estimate that 99% of today’s healthcare data is wasted.