Risk Adjustment, Compensation, and the Implications of VBC Expansion

Moving into 2025, value-based care (VBC) is poised for significant expansion, even as providers are forced to optimize traditional fee-for-service systems to recapture flagging margins. This underscores the importance of enhancing primary care capacity, the integration of health equity initiatives, and preparation for new payment models. Furthermore, the introduction of the new CMS-HCC risk adjustment model Version 28 will significantly alter Medicare Advantage capitation rates and methodologies, necessitating major adjustments in financial planning and resource allocation.

Integrated Best Practice Takeaways

• Tech-Enabled Efficiency: Utilize AI and advanced data analytics across the VBC continuum to simplify complex, multifaceted value-based care (VBC) challenges.
• Navigate CMS-HCC Changes: Anticipate and adapt to the CMS-HCC model Version 28 changes, positioning your organization for financial success.
• Invest in Primary Care and Specialty Improvements: Enhance access, capacity to meet evolving demands.
• Adopt Flexible Payment Models: Embrace episode-of-care and bundled payments for greater financial flexibility and focus.
• Champion Equity: Embed social determinants of health (SDOH) and health equity considerations to ensure comprehensive and inclusive patient care.
• Adjust Financial Planning: Adjust financial and resource allocation strategies in anticipation of the increased risk-adjusted payments to Medicare Advantage plans.
• Leverage Emergent Players: Utilize the unique positions of community pharmacies and home care providers to bridge care gaps and enhance patient engagement within VBC frameworks.