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    Cristy Good
    Cristy Good, MPH, MBA, CPC, CMPE

    Medical practices are aware of the importance of value-based care, but the path has been a challenge.

    Value has been defined as outcomes divided by the costs and resources needed to achieve them, but it should also be viewed in the context of shifting away from a volume-based, fee-for-service world that’s dominated care delivery over the years.

    That shift toward value requires many new approaches. In a combined research report between MGMA and Humana in 2022, data analytics/reporting platforms, population health management tools and EHR tools were the top technological additions to boost value-based plan participation.

    That broad adoption seems to be working: Fewer medical groups report a lack of data and reporting as a major challenge compared to the 2019 research, suggesting that these tools have been implemented and put to good use in support of the shift to value.

    Emerging technology such as telehealth, remote patient monitoring and AI are poised to aid healthcare providers as they continue the road toward value. In particular, AI has the potential to significantly benefit value-based care by enhancing efficiency, improving patient outcomes and supporting cost-effective healthcare delivery. AI already has several applications across healthcare, including:

    • Diagnostic imaging
    • EHR algorithms for extracting and analyzing information from unstructured notes
    • Predictive models for patient outcomes, readmission risks and disease progression
    • Chat bots for patient scheduling and engagement
    • Surgical robots
    • Genomic sequencing

    Consider these 10 areas in which AI can be leveraged to support value-based care:

    1. Risk stratification and predictive analytics
      • Use case: AI algorithms can analyze patient data to identify individuals at higher risk for certain conditions or adverse events.
      • Benefit: By stratifying patients based on risk, healthcare providers can proactively target interventions, allocate resources efficiently and implement preventive measures, aligning with the goals of value-based care.
    2. Population health management
      • Use case: AI tools analyze large datasets to identify trends, patterns and high-risk patient populations.
      • Benefit: Population health management powered by AI enables providers to implement targeted interventions, preventive strategies and personalized care plans, contributing to improved outcomes and cost-effectiveness.
    3. Care coordination and communication
      • Use case: AI-driven communication tools facilitate seamless information exchange among healthcare providers, improving care coordination.
      • Benefit: Enhanced communication ensures that all members of the care team have access to relevant patient information, supporting collaborative care and reducing duplicative efforts.
    4. Clinical decision support systems
      • Use case: AI-based clinical decision support systems analyze patient data and provide evidence-based recommendations to healthcare providers.
      • Benefit: Improved decision-making leads to more accurate diagnoses, personalized treatment plans and adherence to clinical guidelines, enhancing the quality of care and aligning with value-based care principles.
    5. Telehealth and remote monitoring
      • Use case: AI-enabled telehealth tools and remote monitoring devices collect and analyze patient data in real-time.
      • Benefit: Remote monitoring allows for proactive intervention, early detection of issues, and improved patient engagement, contributing to better outcomes and reducing unnecessary hospitalizations.
    6. Financial analytics and resource optimization
      • Use case: AI analyzes financial and operational data to identify areas for cost savings and resource optimization.
      • Benefit: Providers can optimize resource allocation, identify cost-effective interventions and improve financial sustainability, aligning with the cost-containment goals of value-based care.
    7. Patient engagement and education
      • Use case: AI-driven chatbots and virtual assistants provide personalized patient education, reminders and support.
      • Benefit: Personalized engagement enhances patient education, encourages adherence to treatment plans and empowers patients to take an active role in their care, leading to improved outcomes.
    8. Fraud detection and prevention
      • Use case: AI algorithms analyze claims data to detect anomalies and patterns associated with fraudulent activities.
      • Benefit: Identifying and preventing fraudulent billing practices ensures that resources are used appropriately, contributing to cost containment and financial integrity in value-based care models.
    9. Quality improvement initiatives
      • Use case: AI supports quality improvement initiatives by analyzing performance data and identifying areas for enhancement.
      • Benefit: Continuous monitoring and data-driven insights help providers identify opportunities for improvement, implement evidence-based practices, and demonstrate improved quality of care.
    10. Social determinants of health (SDoH)
      • Use case: AI tools integrate and analyze data related to social determinants of health.
      • Benefit: Addressing social determinants enables providers to develop more comprehensive care plans, improve care coordination and reduce disparities, aligning with the holistic approach of value-based care.

    Ways AI can have an impact on value-based care:

    • Conduct risk stratification and predictive analytics to proactively manage high-risk patients
    • Enable comprehensive population health management through big data analysis
    • Facilitate care coordination and help achieve the goal of seamless information exchange
    • Provide personalized patient engagement, education and remote monitoring
    • Assist clinicians with evidence-based decision support and optimize resource utilization.

    Incorporating AI into value-based care models will require planning, data governance, and consideration of ethical and privacy concerns.

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