Data Drives Value-Based Healthcare

The following is a guest article by David L. Morris, EVP & Chief Commercial Officer of Cedar Gate Technologies.

scientia potentia estKnowledge is power.

Acquiring knowledge through advanced analytics on value-based care is a critical success factor in today’s healthcare market. Value-based care aligns diverse interests, including payers, providers, self-funded employers, third-party administrators, brokers, consultants, and patients—value-based care empowers them to deliver, manage, and drive higher patient outcomes while meaningfully managing and decreasing healthcare costs.

A recent study of healthcare consumers found that 62% of respondents were unfamiliar with the term “value-based care” as it relates to their healthcare experience. Yet, the survey also listed lower costs and improved care quality as the highest priority when payers and patients consider insurance plans, indicating that the marketplace already embraces the idea of value-based care.

The pressing, central issue to all of us is that the fee-for-service healthcare model is no match compared with the value contributions gained through the comprehensive and holistic value-based care paradigm. As payers and providers seek models to drive higher-quality and lower costs, value-based care adoption is a credible and sound alternative.

What Is Value-Based Care?

Value-based care drives early intervention, which results in demonstrable and sustainable healthcare savings for payers and supports better patient outcomes. This is especially relevant when considering the continuing rising expenses related to healthcare. For example, in 2016, a study on primary care spending in the United States showed total healthcare costs increased from $810 billion to $1.6 trillion. Additionally, specialty care accounted for 75% of healthcare spending in the United States.

For primary care physicians (PCPs), it means pairing their expertise with best-in-class, high-performing quality specialists who cost-effectively drive the best possible outcomes for the patients they serve.

Rather than PCPs being compensated based on the number of provided services and visits, value-based care incentivizes PCPs to have available underlying clinical and Social Detriments of Health (SdoH) data to prioritize care and intervene appropriately. By steering patients to the most effective treatment options or specialists as well as lessening, mitigating, and preventing the impact of advancing chronic or more severe conditions, the industry can ultimately lead to healthier patients and a more sustainable, high-quality, cost-efficient healthcare ecosystem.

The transformation to value-based care requires moving from the commonplace fee-for-service model into partially or fully capitated business models. Other value-based options include upside only, upside-downside, and retrospective or prospective bundles. The benefit to the patient is treatment programming focused on prevention and the future. The advantage to the payer is decreased costs associated with necessary and aggressive interventions due to worsening conditions. When embraced, the benefit for PCPs and specialists is predictable and brings a consistent source of revenue, enabling them to build practices of medicine driven by care.

Technology Supports Transformation

Value-based care’s acceleration results from rising costs, a needed increased focus on quality, and advancing enabling technology. Providers have been leveraging varied, siloed point solutions and are confounded by confusing data definitions across many platforms that struggle to provide a complete picture of the patient’s journey. Payers and providers have faced the challenge of interpreting disconnected data that inevitably require manual interpretation and leads to bottlenecking of healthcare services.

The reality is that value-based care requires a robust technology platform integrated with homogenized and streamlined data to create accessibility at the patient level to reduce risk-equation gaps. This has been one of the biggest struggles within value-based care and a key reason its adoption has been hampered.

The longitudinal, value-oriented member-patient record is at the heart of supporting direct care initiatives and business operations. A key challenge in doing so has been combining information from disparate sources to create complete member and patient profiles. Data types need to be predefined, cleansed, and normalized to fully integrate a value-based continuum solution and generate this type of record. A data lake is required in order to create accessible clinical, financial, and social determinant records that reflect an individual’s interactions with providers across their care journey. The normalization of patient data is essential to enabling a consistent view of an individual’s health for optimal decision-making and interventions by the provider while also aligning financial models with the payer.

In the value-based care journey, it’s necessary to align both payers and providers in a collaborative dynamic in care arrangements. Depending on where providers are in their journey—upside-only all the way to shared savings models—requires a software framework for bundled payments and global capitation. Additionally, most providers need to gradually shift from fee-for-service to value-based care, thus requiring a modular tool to compose a solution that supports their business model now and into the future. Their risk tolerance is poised to grow over time and with real-world experience.

Another piece of the puzzle is integrated value-based care payment technology. A platform is needed to enable the unique and complex payment adjudication for primary care, specialty care, and global capitation. New models and platforms can now manage retrospective and prospective bundled payment adjudication within a system to establish a highly efficient payment process in a composable framework that supports the necessary flexibility.

To administer a solution successfully and as efficiently as possible, well-thought-out administration is also critical. Coordinated and synchronized payer-provider payment models drive efficiencies while reducing risk for providers. A solution must be in place to enable IT to manage primary, specialty, and global capitation and design and optimize, retrospectively and prospectively, via bundled payment models.

Healthcare needs to, and is, advancing. Comprehensive, integrated platforms now offer a new path forward. Value-based healthcare can drive high-performance clinical outcomes through technology with improved financial outcomes. Providers need more time to focus on early interventions and the tools to access data to impede disease progression and manage chronic conditions. Meanwhile, payers must reduce the steep financial burden and high risk of late interventions. By solving the complex data issue through advanced technology and creating transparency, payers and providers can achieve more efficient and effective healthcare. The intermix of critical technological solutions, with normalized data as the foundation, can create a better equation that delivers the promises of value-based healthcare—benefiting everyone on the continuum.

   

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