Healthcare- one of the critical pieces of all of our lives, is observing a tremendous transformation in terms of medical service provisions. But that is not all. The pharmaceutical industry is moving by leaps and bounds when it comes to improving patients’ lives, not just in terms of health but in terms of money as well. You ask how? Here is the answer. The Center for Medicare & Medicaid Services (CMS) – a US Department of Health and Human Services (HHS) federal agency, that works in unison with state governments, has taken it upon itself to administer Medicaid and other health insurance portability standards.

As a federal agency, CMS is known across the healthcare industry for its value-based programs that empower and reward medical care service providers based on their quality of service to us, patients. However, it is still a surprise that most of us remain unaware of this trivia. Why not explore more about CMS, its value-based programs, and the benefits it brings to the table for every healthcare service provider?

What are the Value-based Programs?

This might have been the first question that popped into your mind while reading the above paragraph. Here is what Value-based programs mean: “programs that reward health or medical care providers in the form of incentive payments for their quality of service to patients who own Medicare.” As per CMS, such value-based programs are a part of their strategy to reform the ways healthcare is delivered, obtained, and paid-off for, by us. In short, CMS aims to achieve and support three significant elements of the medical field –

  • Improved health services to patients
  • Improved health services for populations
  • Reduced service cost

What are the value-based programs of CMS?

Not to mention, but CMS has a list of its value-based programs that are designed specifically for healthcare service providers and people like us, who own Medicare and Medicaid. The goal of these programs is to establish a defining link between the healthcare service quality measures with the provider payment.

  • End-Stage Renal Disease Quality Incentive Program (ESRD QIP)
  • Hospital Value-Based Purchasing (VBP) Program
  • Hospital Readmission Reduction Program (HRRP)
  • Value Modifier (VM) Program or Physician Value-Based Modifier (PVBM)
  • Hospital-Acquired Conditions (HAC) Reduction Program

All of these are the original value-based programs offered by CMS; all of them have different timelines, and all of them have distinct quality and standards. So, if you’re a healthcare service provider, do dig into these to enjoy the multifold benefits CMS offers.

However, CMS is now encouraging healthcare service providers and market innovators to modernize and improve all these programs by leveraging Artificial Intelligence (AI), to try and eliminate medical fraud that a few of us might have experienced firsthand.

To accomplish the same goal, CMS has launched a new initiative, ‘The CMS Artificial Intelligence (AI) Health Outcomes Challenge.’ Within this initiative, CMS is calling all innovators to demonstrate their creative and inventive skills and show how AI tools can prove beneficial for enhancing value-based programs and curbing medical payment fraud.

How can AI help make CMS value-based programs better for patients as well as doctors?

  • Eliminating medical payment fraud –

By adopting AI, the federal government agency is solving complex issues related to fraudulent and improper payments, effectively and efficiently. This approach has saved around 42 billion dollars of the government

  • Building Recommendation system –

Another compelling use case of AI in healthcare is to understand and analyze unstructured patient data. Many of us do not pay heed to our medical or grant data collected by the service provider, but they sure do matter. AI-powered grant recommendation systems come handy in suggesting the end-users another potential grant opportunity that might interest them, based on previous data and interest of similar users.

  • Smart search –

Gone are the days when you had to scan through multiple plain texts to solve any query. Today, AI-based searches enable people to put forth their questions related to available grant opportunities or other unstructured data by using natural language processing (NLP).

  • Fewer visits to the doctor –

AI-powered tools and machine learning algorithm overcome complex patient care challenges and reduce the number of visits to the doctors’ clinic. How? By making remote diagnosis a reality and suggesting necessary medical tests.

  • Improve EHR data access –

CMS is looking at the opportunity to explore the benefits of AI and machine learning, to expand and enhance EHR tools’ use. By doing so, these tools offer the promise of a seamless and accurate review of chart documentation during the medical evaluation, ensuring that what we pay for, is what we receive and vice versa.

  • Extend the life of Medicare Trust Funds –

Yet another benefit of AI is that it would work wonderfully in extending the life of Medicare Trust Funds. Tools using AI as their native technology will help us to repeal the use of outdated, expensive, and inefficient payment methods, thereby protecting the interests of numerous beneficiaries.

  • Data sharing and security –

You know how important your data is. Then, is it not imperative for your healthcare service provider to keep your medical records safe from external or internal breaches? In fact, it is. CMS is also stressing over the use of AI tools to ensure that data sharing among different medical practitioners is facilitating but in a secure environment.

What is the Conclusion?

In a simple sentence, embrace technological advancements and keep the medical information safe. This duo will not only transform the way CMS has been upholding and offering its value-based programs but also help us, as well as medical practitioners in ensuring that the pay is equal to the medical service received or provided.

Another conclusive statement that could be made from the above information is that the introduction of AI and machine learning algorithms are critical to curbing the fraud instances that often make patients and doctors their target. Clearly, wouldn’t it be better and accessible for all of us to connect with the doctors, follow the required medical procedures, process the payment, and live happily ever after? This is exactly what CMS is aiming to achieve by including AI in its programs and other operations.

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