Healthcare business models are shifting to more innovative reimbursement structures, partly due to the unsustainability of the current fee-for-service approach that is increasingly unsustainable. Instead, ‘value-based care’ models, are being employed by regulators and health plans with hopes of addressing societal concerns regarding cost and quality of care. At the forefront of this major shift in the industry, one of the largest experiments in value-based care is underway in the state of Maryland with the ’Total Cost of Care’ model.

Maryland’s Approach Towards Value-Based Care: The ‘Total Cost of Care’ Model

The Total Cost of Care model is an evolution of the all-payer model in which Maryland’s hospitals and health systems are incentivized to collaborate to drive efficiencies in healthcare delivery and improve health outcomes for patients. This approach seeks to reduce expenditures and improve quality by reducing unnecessary care incentivized under traditional fee-for-service models and promoting more coordinated care in hopes of reducing costly readmissions.

The positive impact this model could have on the current healthcare landscape is evident amongst leaders in the industry. Redonda Miller, M.D., M.B.A., President of The Johns Hopkins Hospital in Baltimore, expressed her support for the Total Cost of Care payment model at the World Health Care Congress gathering earlier this year stating, “The idea is to keep people out of the hospital, and we embrace that. We’re focusing on improving post-acute care strategies and reducing emergency room visits.”

Driving Connectivity through CRISP

Despite praise for the Total Cost of Care model, there’s also apprehension within the provider community, specifically regarding accountability for patient outcomes outside of their direct oversight. With additional collaboration comes additional risk in the form of limited knowledge and control over care delivered outside of their own facility. This is a point of concern for providers as the reimbursement structure holds all providers accountable for patient outcomes regardless of who delivered the service.

In order to mitigate this concern, hospitals, payer organizations, and state regulators in Maryland are investing in CRISP, the non-profit regional health information exchange (HIE) serving Maryland and the District of Columbia. The HIE is collectively owned by leading healthcare institutions in the region, and the organization is funded by providers and payers who subscribe to the exchange. Additionally, in the interest of promoting transparency, CRISP engages a broad array of key stakeholders in its advisory boards and Board of Directors.

CRISP enables providers, payers, and public health stakeholders to communicate more efficiently and effectively. The HIE has long supported the reduction of hospital readmissions by enabling communication throughout the care continuum, and was an early adopter of Audacious Inquiry’s Encounter Notification Service®, which was designed to decrease near-term readmissions by prompting providers to follow-up with their patients and ensuring they have a clear understanding of their hospital discharge instructions. Amidst privacy concerns, CRISP also enables patients to take ownership of the sharing of their data, by way of state-regulated ‘opt-out’ consent capability. As a function of engagement by its’ stakeholders, CRISP has become among the most successful organizations of its type in the country and a thought leader among health information organizations.

Unique Model, Unique Outcomes

Interconnectivity between patient care teams via real-time clinical data and information exchange has increasingly influenced the healthcare delivery system in Maryland. Opening these channels of communication has fostered a more patient-centered care model that’s driven clinical and financial results across the state. As shown below, from 2013 until 2018 hospital payments nationwide increased by 9.3%, while Maryland only witnessed a 3.6% increase. Furthermore, over the same time period, Maryland experienced a decrease in inpatient care and a significantly lower growth rate of outpatient care while utilization of hospital services across the nation continued to rise.




This reduction in hospitals services can be attributed to efforts across the state to drive prevention and public health efforts, reduce readmission rates, and improve chronic care management by leveraging the powerful insights and tools available within the HIE platform. Through the Total Cost of Care model, Maryland is targeted to achieve $300 million in annual Medicare savings by 2023 at the same time national health expenditures are projected to rise to 19.3% of GDP.

Maryland’s unique model, coupled with the advanced health information exchange operated by CRISP, has given Maryland’s healthcare organizations an extraordinary platform on which to drive system-wide improvements for patients across the state. The value-based care experiment in Maryland has revealed the potential that exists for states to reshape their healthcare system and address cost and quality issues through empowering partnerships and collaboration on data exchange.   Importantly, the successes of CRISP and the Total Cost of Care Model in Maryland demonstrate the importance of enabling flexibility in policy, such that innovation similar to what we have witness in Maryland is not stifled by national, one-size-fits-all governance.


Chris Brandt Headshot

Chris Brandt
Chief Executive Officer (CEO) | Audacious Inquiry