Mastering the shift to value-based care: 3 strategies for organization-wide success

© Chinnapong - stock.adobe.com

As health care organizations progress on their value-based care journeys, clinicians and other staff members are discovering just how uniquely difficult the transition can be. The main challenges they face include an increased administrative burden, data overload and resource-intensive processes for both risk adjustment and quality performance, all of which can take a serious toll on morale. In the face of these challenges, cutting-edge technologies such as artificial intelligence (AI) are creating new ways to ease the shift to value-based care.

In my years of value-based care leadership roles, I experienced daunting challenges firsthand — but I’ve also seen how forward-thinking organizations can use technology to overcome them and thrive.

Dana McCalley, MBA
_{© Navina}

This article will present three key strategies that I have seen make a particularly powerful difference for health care organizations as they transition to value-based care.

1. Code smarter, not harder

For value-based health care organizations to be financially sustainable, risk adjustment is essential. To quote the Centers for Medicare & Medicaid Services (CMS), risk adjustment aims to ensure that “doctors and other health providers are paid fairly for the people they treat — providers get paid more for patients who have more health problems than for healthy patients who may not need as many services.”

Risk adjustment relies heavily on the time-consuming process of hierarchical condition category (HCC) coding, which can come at the expense of the time primary care physicians dedicate to actually delivering patient care. The current transition from the V24 model of HCC coding to the new V28 model further adds to that challenge. The V28 model includes significant updates, such as adjustments to condition groupings and risk weights, designed to better align coding with contemporary health care needs. With many clinicians needing to deal simultaneously with both coding models, there is a real risk of incomplete coding, which translates into lost revenue for health care organizations.

Coding often requires physicians and coders to deal with large and often overwhelming volumes of information, much of it spread across paper records, electronic health records, health information exchange feeds, claims data and other sources. Even though this data is digitized, much of it is still unstructured and unsearchable.

AI changes all of that, allowing for streamlined HCC coding. By analyzing all available patient data (regardless of format) to suggest diagnoses that were likely missed, AI can help clinicians ensure that their coding is complete while also saving valuable time. This can help health care organizations avoid the lost revenue that can result from incomplete HCC coding and allow physicians to focus more on delivering care. Ultimately, this benefits physician morale, health care organizations’ financial health and the quality of care that patients receive.

2. Beyond spreadsheets: efficient care gap management

Strong quality performance, including high Medicare Star Ratings and Healthcare Effectiveness Data and Information Set (HEDIS) scores, is another key tenet of value-based success. Not only does enhancing quality performance improve patient care, these measures can have a major financial impact. CMS offers significant incentives for strong quality performance, and it publishes annual data on health care organizations’ Star Ratings that can affect their future enrollment numbers.

Looking at the state of value-based care in the U.S. in general, there is significant cause for concern. A white paper by Milliman that analyzed CMS data found that “the 2024 Star Ratings continue a downward trend, with the national average rating now at the lowest overall point since 2017 for MA-PDs (Medicare Advantage Prescription Drug Plans) and since 2014 for Prescription Drug Plans (PDP)… Additional reductions to plans’ Star Ratings may be coming over the next few years, with new measures and weight changes impacting plans’ 2026 ratings and a new rewards methodology — the Health Equity Index (HEI) — impacting plans’ 2027 ratings.”

Improving quality performance entails identifying and closing care gaps. That can be a major challenge, especially because of the volume of patient data at physicians’ fingertips.

Once care gaps are identified, closing them does not always require active steps such as preventive screenings. In many cases, a care gap can be closed by discovering evidence either that a patient has already received a certain intervention or that they’re ineligible for it. But making those kinds of determinations also often requires combing through and making sense of large volumes of patient data.

By analyzing patient data to identify and close care gaps, AI can empower health care organizations to improve their quality performance. It can also save significant time for clinicians, allowing them to focus more on patient care. As with streamlined HCC coding, this can benefit physicians, health care organizations and patients.

3. Breaking silos, building synergy

Value-based care takes a more holistic approach to patient care than a conventional fee-for-service model. As a consequence, it requires more coordination, collaboration, cooperation and communication, not only among physicians, but also among other team members and with the patient.

Value-based care also places other demands on physicians. For instance, if a patient requests an appointment on short notice, accommodating that request — while likely inconvenient — can both improve health outcomes and save money. Agreeing to steps like these can sometimes help avoid unnecessary emergency room visits. The problem is that these higher expectations of physicians, combined with the increased administrative burden, can also increase the risk of clinician burnout.

In this challenging new reality, a culture of teamwork is required to help facilitate the necessary coordination, collaboration, cooperation and communication. It can also serve to boost morale across the entire clinical team.

Fostering teamwork entails strengthening clinicians’ sense of camaraderie and of being appreciated for their work. Having clearly defined procedures and organizational values can also help significantly with this effort, as can professional mentoring. Having physicians serve in leadership roles can also make a powerful difference, giving doctors a voice and helping ensure that organization-wide policies reflect an understanding of the day-to-day challenges they face.

Dana McCalley, MBA, is the vice president of value-based care at Navina. She has 15-plus years in health care with a focus on quality improvement and risk adjustment. She led one of the nation’s top-performing accountable care organizations for nine years and was responsible for helping 700-plus clinicians provide care to 230,000 value-based patients.