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