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.