Enhancing Program Administration in Health Care
Health care organizations in 2025 will continue to migrate from traditional fee-for-service (FFS) toward value-based care (VBC) and other risk-based alternative payment models. However, no matter what reimbursement models are in play, program administration is critical to achieving success. Health care organizations operating without effective program administration will struggle to meet quality-of-care targets, manage utilization, issue payments, or control costs—regardless of reimbursement model.
Successful program administration uses data to ensure that participants in a payment contract are aligned to accomplish shared objectives that result in better patient outcomes and experiences. Participants may include one or more primary care providers, multiple specialists involved in chronic disease management, and community-based organizations. Real-time patient information can inform evidence-based care decisions, improve care coordination, and prompt appropriately timed interventions. Likewise, incorporating social determinants of health (SDoH) and population health data supports a holistic, or “whole person,” approach to patient care that emphasizes wellness and prevention.
Care Alignment and Resource Allocation
Regardless of policy changes implemented by the new federal administration that impact health care, cost control, and care optimization will be more important than ever as the US population ages and the demand for affordable care increases. Efforts to improve Medicaid program administration, increase health care access for rural Americans, and support employer-driven health initiatives should extend through 2025 and beyond.
Effective health care program administration relies upon an understanding of assigned patient cohorts and the strategic deployment of resources. This begins with a population health analysis that identifies high-risk patients (eg, patients with polychronic diseases) who require an elevated level of care management.
Resource allocation is another key element of program administration. Health care organizations must have a strategy for deploying resources to provide appropriate care to patients with high utilization. In addition, program administration is responsible for ensuring that care delivery aligns with a network’s reimbursement model.
The Impact of AI
Artificial intelligence (AI) has the potential to dramatically improve health care program administration, particularly through digitizing and processing massive volumes of data for decision support. AI models applied on top of already digitized data that are categorized properly may provide useful insights and the creation of more robust programs.
To get the most from implementing AI, a baseline of at least 60% of data must be digitized. Falling short of this threshold compromises AI’s ability to generate actionable insights. Given that roughly 80% of health data is in an unstructured form and not categorized in proper context, there first must be more progress within data engineering to realize AI’s full potential to transform health care.
A lot of firms are developing tools to improve data digitization by putting unstructured data into structured formats, making it accessible to AI for analytics that support decision-making. Other companies are leveraging AI tools such as natural language processing (NLP) and computer vision to process patient records and optimize workflows. Creating comprehensive ecosystems that combine structured and unstructured digitized data helps streamline program administration and subsequent processes that support the network.
Program Administration Building Blocks
Program administration success begins with understanding the needs of the care population. Cost and utilization data are especially important to create an accurate population profile. Analysis of utilization data may uncover duplicate or unnecessary services that reduce costs when eliminated.
The second step is to optimize engagement across the care continuum through the identification of key referral patterns, streamlining of provider interactions, and enhancement of coordination across care teams.
Finally, improving data standardization by normalizing patient records and implementing interoperability standards can facilitate seamless and timely data sharing among stakeholders in the network.
Conclusion
Health care delivery and reimbursement models will continue to evolve to meet market needs and take advantage of technological innovations that improve care coordination and operational efficiency. Program administration that enables data-driven decision-making, care team alignment, and proactive population health management will best position these models to thrive.
About the Authors
Rahul Sharma is the chief executive officer and Lynn Carroll is the chief operating officer of HSBlox, an Atlanta-based technology company empowering health care organizations with the tools and support necessary to deliver VBC successfully and sustainably. Carroll also serves as an editorial board member for First Report Managed Care.
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