Latest / Becker’s Payer Issues Podcast / Capitalizing on Momentum: Payer Perspectives on Value-Based Care in 2025

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Capitalizing on Momentum: Payer Perspectives on Value-Based Care in 2025 · Becker’s Payer Issues Podcast

0:00
Hi, everyone. This is Lucas Voss with Becker's
0:01
Healthcare. Thanks so much for tuning in to
0:03
the Becker's Healthcare podcast series. It's great to
0:06
have you. Today, we're going to talk about
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capitalizing
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on momentum, payer perspectives
0:11
on value based care in 2025.
0:15
And joining me for today's discussion, very excited
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to have her, is Carrie Kettleson, president at
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Vertex Health. Carrie, thanks so much for being
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here today. It's great to have you.
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You're so welcome. Happy to be here. Thank
0:28
you for the warm welcome.
0:30
Absolutely. It's fantastic to have you. Well, before
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we get started here, could you introduce yourself
0:35
to our audience and share a bit about
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your work in health care?
0:39
I'd be happy to. Who doesn't like to
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talk about themselves? Right? Right.
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So currently, I serve as the president of
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Vertex Health.
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I lead a team focused on delivering technology
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enabled solutions that drive financial and clinical
0:57
performance across the health care ecosystems.
1:00
So at Vertex Health, we offer bespoke solutions
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for both payers and providers.
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Our solutions are focused on clinical data retrieval,
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interoperability,
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risk adjustment coding,
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quality, heat of subtraction,
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and advisory and consulting
1:17
around all of these areas. We also have
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a platform that's a self-service tool that can
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be used by both payers and providers alike
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for any of these use cases.
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One quick thing that I'd also like to
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mention is, you know, with our services and
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our resources,
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especially around coding,
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we have the largest employed coding team in
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the industry
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specific to risk adjustment. We have have over
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13,000
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coders with experience and expertise in all forms
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of risk adjustment coding,
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all lines of business. So that includes
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Medicare, ACA, Medicaid,
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as well as Radb e purposes.
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We offer retrospective,
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prospective, concurrent,
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and claims validation.
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So a little bit about Vertex Health there.
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I think for myself, over the course of
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the career my career, I've had a unique
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opportunity
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to work across a full spectrum of health
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care.
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So operating on behalf of payers, providers,
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and large integrated health systems.
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That end to end experience has really given
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me a deep practical understanding
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of how health care is delivered,
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reimbursed, and optimized.
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It's also really shaped my ability to identify
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where friction exists. You know, what are the
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problems that we need to solve and how
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to remove it,
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whether it's through data automation
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or better alignment across stakeholders.
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So I'm very passionate about helping organizations
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scale value based care in ways that are
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sustainable, collaborative, and human centered.
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And And it's fantastic to have you on
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simply because of that tremendous experience
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and the problem solving aspect to this. I
2:58
wanna jump into our conversation here. The joint
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report from the National Association of Accountable ACOs
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and health tech company Innovexxer,
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They showed more than 60%,
3:08
sizable number of respondents, anticipate increased revenue
3:11
from value based care, and we'll refer to
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it as VBC just to make it a
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little bit shorter.
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And I'm curious from your perspective,
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what's driving this momentum right now, and what
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are some of the implications for pairs as
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they're navigating this environment?
3:28
Great question. I think so let's talk a
3:31
little bit about, you know, kind of three
3:33
points on the momentum and then get into
3:35
those implications.
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I think a couple of key pieces on
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the drivers for momentum.
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Number one would be just policy and regulatory
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support.
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CMS has set an ambitious goal to have
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all Medicare beneficiaries
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in an accountable care relationship by 2030.
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This policy direction is accelerating
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the adoption of alternative payment models and it's
3:58
providing a clear pathway for providers and payers
4:02
to transition from fee for service to value
4:05
based arrangements.
4:06
I think the second big piece would be
4:09
advancements in technology
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and really around the integration of advanced technology
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such as AI and predictive analytics. It's really
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enabling payers and providers to better manage population
4:20
health.
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And these tools are really facilitating
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proactive care.
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They can identify at risk patients as early
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as possible. There's personalized interventions.
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And, ultimately, this leads to improved outcomes and
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cost savings, which is the name of the
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game. It's what we're all after. And then
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finally, I would say that there's, you know,
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financial incentives and market dynamics that are playing
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a role here.
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The financial benefits of VBC, you know, whether
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it's shared savings or performance based incentives, are
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becoming more and more apparent. And then additionally,
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you've got influence from private equity interest in
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physician practice management.
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That's increasing.
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We're seeing, you know, particularly in specialties that
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align with VBC,
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and it's further driving the adoption of these
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models.
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As far as implications for payers, you know,
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as as payers navigate this evolving landscape, several
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considerations are paramount.
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Strategic partnerships,
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critically important. So collaborating with value based care
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enablers and streamlining the transition process.
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You know, these partnerships help reduce administrative
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burdens. They standardize payer provider interactions,
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enhancing care coordination,
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ultimately leading to those better health outcomes.
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Data is all always a big topic here,
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specifically around integration
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and analytics.
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So investing in that robust data infrastructure is
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crucial.
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Seamless integration
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of clinical, financial, operational data, it allows for
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informed decision making, effective risk management, and targeted
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interventions that improve patient care and reduce costs.
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And then finally, you know, at the heart
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of all this is the patient and the
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member. So member engagement and support,
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engaging members through personalized care management programs,
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wellness incentives,
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supporting, you know, for social determinants of health,
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those can enhance the participation in these BBC
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initiatives.
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And this approach also fosters a more patient
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centered care model and also contributes to better
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health outcomes.
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Those are the kind of the high points.
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I think in summary, I would say the
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anticipated increase in revenue from
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VBC is driven by supportive policies,
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technology advancement,
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financial incentives.
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And payers that embrace these strategic partnerships, they
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invest in the data integration, and they focus
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on member engagement,
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will be well positioned to thrive in this
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evolving
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health care landscape.
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Yeah. Absolutely. There's a lot of moving parts
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of this, which I think you all mind
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very, very nicely, and that's obviously making things
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more complicated for organizations.
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That's why they need good partners as as
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you've outlined.
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There's obviously a lot of optimism around this.
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There's a lot of positives, a lot of
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talk about growth and the opportunities this brings,
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but there's also the worry about sort of
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the barriers that come with it and that
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organizations
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are presented with.
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How should payer organizations think about supporting provider
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readiness in all of this while keeping their
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own strategic goals
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in mind?
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That's a great question, and one that's more
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relevant than ever. Not only just what we're
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talking about today, but recent
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items in the news, recent policy and regulatory
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things that are being considered that are still
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to be determined are going to influence this
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as well. Mhmm. Payer organizations are under immense
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pressure. They need to grow, they need to
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manage their risk, and they need to improve
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patient outcomes.
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But none of that is possible without strong
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aligned partnerships with providers.
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And supporting provider readiness, you know, isn't just
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a nice to have. It's essential for advancing
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shared value.
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In order to do this effectively,
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payers need to think beyond transactional
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relationships
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and shift more towards strategic collaboration,
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which means investing in data transparency,
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workflow integration, and tools that truly support providers
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at the point of care.
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You know, it it also I think it
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means listening.
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Mhmm. Understanding the operational realities provider space and
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co designing solutions that align with their capacity
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and incentives.
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At the same time, payer organizations have to
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stay grounded in their own strategic goals. The
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key is to identify
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the overlap
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in areas where provider success directly
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aligns and supports payer outcomes, whether it's improved
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risk adjustment, quality metrics, or patient experience.
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And by approaching growth as a joint effort
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where you've got shared accountability and aligned incentives,
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I believe we can move the industry forward
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in a way that's both scalable and sustainable.
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You know, that's one of the things we've
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seen at Vertex Health. We've seen the power
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of tailored enablement where payers give providers the
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insights and infrastructure they need while preserving that
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clinical freedom.
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And this balance is what drives long term
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success.
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Yeah. Absolutely. And you've touched on on it
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earlier and now again, which I think is
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very, very crucial to this. Right? We talk
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about technology. We talk about you've touched on
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AI,
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but you've also, you know, talked about data
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analytics and insights. And and the survey that
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we highlighted at the beginning of our conversation
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also
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showed that 70% of respondents were
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expressing confidence in these tools and AI and
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technology to scale their strategies.
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How are you seeing payers use these technologies
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to improve?
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And I also am really interested in this
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too.
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Are you particularly
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excited about anything that's coming up that you've
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been seeing heading into the second half of
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the year here?
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Great question. So, yes, I'm excited. So I'll
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talk a little bit about high level, and
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then I'll talk about some of the pieces
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that I think particularly
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are exciting and could really have a major
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influence in this space.
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AI and data analytics are absolutely transforming how
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payers approach value based care.
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We're seeing organizations
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use these tools to identify care gaps. They're
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stratifying patient risk.
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They can predict future utilization
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with impressive accuracy.
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So this allows for more proactive targeted interventions
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that not only improve outcomes, but they drive
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the efficiency and the cost savings. Mhmm.
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What's exciting right now is the shift from
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retrospective reporting to real time actionable insights.
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For example,
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using an AI driven coding assistant or a
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predictive model at the point of care.
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This helps providers document accurately in the moment,
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so this improves risk adjustment reporting and also
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quality scores without adding administrative burden.
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Heading into the second half of the year,
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I'm particularly
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excited about the advancements in NLP and automation
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and clinical workflows,
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and this includes AgenTek AI and the use
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of large language models, which I'll expand on
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in a moment.
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But these technologies are finally getting to a
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place where they can ease the load on
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both payers and providers, and that's critical for
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scaling
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VBC sustainably.
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So a little bit about why I'm excited
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in some of these these pieces. So AgenTic
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AI
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is is the next big leap in health
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care technology.
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Unlike traditional AI, it doesn't just analyze the
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data. It takes action.
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So think of it as a virtual teammate
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that can schedule appointments,
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close care gaps, optimize coding, or even support
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clinical decision making in real time.
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It has the power to help reduce administrative
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burden, improve outcomes, and scale value based care.
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And the real power is it gives time
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back to providers and lets them focus on
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what matters most,
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caring for patients.
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And as we think about large language models,
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they're actually at the heart of several of
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these AI categories,
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especially NLP,
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generative AI, and agentic AI.
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So LLMs are large language models,
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very heavy buzzword right now in the industry.
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They're really the engine behind a lot of
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innovation we're seeing in health care AI.
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They
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power everything from clinical documentation assistance to virtual
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care agents.
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What's unique about them and different is that
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they it has the ability to emulate human
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reasoning.
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And so their ability to understand, summarize,
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and generate human like language allows them to
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extract insights
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from unstructured data, like clinical notes or medical
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records,
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and even draft progress notes, patient letters, or
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prior auth appeals.
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So LLMs can play a central role in
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agentic AI because not only can they interpret
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intent, but they can also take action across
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systems.
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So whether it's recommending next steps for care
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or helping automate revenue cycle tasks,
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they're enabling a more conversational,
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intelligent layer of automation that's finally intuitive for
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clinicians to to use.
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In in short, I would say LLMs are
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the foundation of a more natural human human
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centered AI in health care, and they're helping
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us turn data into action
13:38
in a way that's scalable and sustainable.
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And all of these pieces are are absolutely
13:43
critical for success in BBC and that ongoing
13:45
partnership and collaboration between payers and providers.
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Yeah.
13:51
You outlined that beautifully. I think I'm just
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gonna cut that to explain LLMs.
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That was a fantastic
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fantastic explanation, and there's so much happening in
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this space. Carrie, thank you so much for
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being on today and sharing your insights. This
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was a fantastic conversation.
14:07
Thank you. I I've enjoyed the conversation.
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I think if I had to add one
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thing, it's just important
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how important it is to stay people focused
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in all of this.
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With all the buzz around AI, data, innovation,
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it's easy to lose sight of the fact
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that everything we do, whether it's improving risk
14:26
adjustment
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or scaling value based care, it's ultimately about
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helping real people get better care.
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I'm I'm excited about where the industry is
14:35
heading, but I'm even more excited about the
14:38
potential we have when we bring the right
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people, tools, and purpose together.
14:43
At the end of the day, progress happens
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when we show up, listen, and lead with
14:47
intention.
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And I think we're on the cusp of
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some really meaningful change.
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So thank you for having me. Much appreciated.
14:56
Yeah. Absolutely. It's more than just the buzzword.
14:59
Right? We need to get over the buzzword
15:01
to action,
15:02
which I think is so key. Thanks again,
15:04
Carrie, for being on, and we also want
15:06
to thank our podcast sponsor, Vertex Health. You
15:09
could tune in to more podcasts from Becker's
15:10
Healthcare by visiting our podcast page at beckershospitalreview.com.