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IDC PlanScape:價值基礎醫療費給付

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

出版商 IDC 商品編碼 359737
出版日期 內容資訊 英文 18 Pages
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IDC PlanScape:價值基礎醫療費給付 IDC PlanScape: Value-Based Reimbursement Demands Payers Execute an Exchanges-Like Level of Effort
出版日期: 2016年06月06日 內容資訊: 英文 18 Pages

本報告提供價值基礎醫療費給付 (VBR) 主張的各方面討論,分析何謂VBR,準備好VBR相當重要的理由,主要的相關利益者,及享受VBR優點的方法等相關資料。

IDC PlanScape的說明圖



  • 價值基礎報酬制度取代個別報酬制度 (付費服務制度)
  • VBR的措施五花米門,鎖定重點的方法
  • Medicare (醫療保險) 擁有EOY2016·2018的正式VBR目標
  • 必需要有契約相關競爭上的優勢
  • 醫療損失率重視長期性利益幅度
  • FFS對供應商而言魅力日益降低
  • 雇主及供應商去中介化


  • 決定想支持的手法
  • 採用了醫療費申請的調整及內建式或並行醫療費給付Logic的工作流程·系統評級
  • 準備中台及後勤部門工作流程·系統

主要的利害關係者 (相關利益者) 是誰?

  • 產品管理
  • 計劃管理
  • 契約管理
  • 請求/客戶服務
  • 財務
  • 評級/費用
  • 照護調整/醫療管理
  • 供應商網路管理
  • 供應商關係


  • 重新考慮精神衛生獨立承保策略
  • 透過產品結構的自動化實行創造性的產品設計
  • 實現Contract Management Agile 流程·軟體
  • 確保從產品到網路定義都能彈性配合
  • 基於何種流程來支援照護的規定、其他



Product Code: US41380616

This IDC study discusses the aspects of value-based reimbursement (VBR) initiatives."Value-based reimbursement will be organizationally and technically pervasive for payers. Similar to what happened in 2012-2015 around the ACA, shockwaves will operationally happen to payers because of value-based reimbursement soon. Hospitals and other providers are working hard to prepare for contract negotiations with payers using alternative payment models (APMs) using fee-for-value methodologies. Payers are experimenting with various methodologies and interpreting Medicare goals and are concerned with their internal pilot programs maturing. They are hanging onto fee for service because that is what is familiar. What is underestimated is the core procedural and systematic changes necessary in the middle and back offices to execute operationally under an environment where soon the majority of payments will be value based", states Jeff Rivkin, research director for Payer IT Strategies at IDC Health Insights. "New paradigms in finance, product definition, contract and rate modeling, and workflow will be established driven by direct change in provider contracting, episode recognition, care coordination, and claims pricing and processing. Fundamental revenue transformation is coming, and it is being underestimated. Most payers struggled operationally with ACA, and similar struggles come with VBR. Think multiyear, multiproject, and multidivision, and start now."

IDC PlanScape Figure

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
  • Finance
  • Rating/Pricing
  • 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
      • Prospective
      • Retrospective
    • Bundled Contracting
    • Primary Care Medical Home
    • Shared Savings (One-Sided Risk)
    • Shared Risk
    • Capitation Full Risk
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