Market Access: Create value, share risk

Q. How can HME providers move beyond fee-for-service to support capitated or risk-sharing payment models?

A. The current demographic trajectory and the escalating complexity of chronic care management have necessitated a fundamental shift in payer strategy. With aging in America accelerating, the home has become an important focal point of value-based care. Payers are shifting from transactional, unit-based cost management toward alternative payment models that favor value creation, shared risk and aligned incentives. To support adaptation alongside these shifts, HME providers should consider focusing on three core areas.

Harnessing the power of data

Providers should understand how to transition from retrospective billing to predictive modeling. By analyzing historical claims and clinical trends, providers can determine per-member-per-month costs and identify high-risk patient segments before expensive acute events occur. This data-driven approach allows providers to establish sustainable capitated rates while proving that proactive DME interventions can contribute to reducing the total cost of care.

Investing in personalized patient journeys

Success in risk-sharing requires meeting patients where they are. This spectrum of care can range from first shipment, unboxing calls that mitigate therapy angst to sophisticated interventions where field technicians serve as eyes in the home to identify relevant social needs and circumstances in the home setting. These personalized touchpoints ensure providers are accountable for whole health wellness, ultimately driving improved outcomes and higher member satisfaction.

Leveraging technology and partnerships

Strategic technology solutions can foster the operational excellence needed to scale risk models. AI-driven automation can help streamline intake and documentation, accelerating speed to therapy initiation. Furthermore, third-party partners can support remote patient monitoring and condition management. These collaborations allow for targeted engagement, which helps clinicians identify the right interventions at the right times to prevent adverse, costly events. By integrating these tools into existing workflows and patient journeys, technology acts as the connective tissue that links operational speed and rigor to improved, measurable outcomes.

Yelena Brusilovsky is vice president, commercial sales, for ADSG | Edgepark.