Accelerating Value-Based Care Transformation Today and Post COVID-19

One year into the COVID-19 pandemic and healthcare leaders are taking a hard look at all operations – especially innovative reimbursement models that best meet the needs of their business, providers and patients. No doubt these leaders are finally paying closer attention to value-based care.

Value-based care, a model that prioritizes patient health quality outcomes versus patient services volume, has the potential to be a silver lining of this pandemic. While once thought to be a lofty, or perhaps overly ambitious goal, value-based care has become a critical approach many healthcare leaders are exploring to stabilize provider reimbursements and improve patient outcomes, while reducing unnecessary costs.

To make value-based care a reality, there are three fundamental steps health leaders should be working toward today.

Set the Foundation: Interoperability

First, health leaders must look at their ability to seamlessly share patient data across the industry. Luckily, the Centers for Medicare and Medicaid Services (CMS) has elevated interoperability as a top challenge and has laid the groundwork for healthcare organizations to improve electronic data exchange. For example, in March 2020, CMS passed the Interoperability and Patient Access final rule, empowering healthcare consumers with access to their health records by introducing opportunities for better data sharing between payers, providers, third-party apps and patients.

These changes along with the decades of innovative interoperability work led by the Da Vinci Project, Workgroup for Electronic Data Interchange (WEDI) and the Council for Affordable Quality Healthcare (CAQH), particularly around Fast Healthcare Interoperability Resources (FHIR), have been a catalyst for improving data sharing across the healthcare continuum and are foundational to a value-based care program today. This is especially important as payers increasingly shift towards capitation models, where they are looking for prospective payments. To act on prospective episodes of care and the sophistication required to operationalize capitation administration, payers will need the data sharing technology to process both adjudicated claims as well as anticipate additional inbound claims.

Evaluate the Playing Field: Systemic Change

Next, system design is critical for healthcare organizations to adopt value-based care, especially at the state Medicaid level. To truly bring these advanced models of care to life, provider groups, community organizations and the state must align on how to incentivize every stakeholder in the healthcare system to embrace value-based care.

While coming together may seem more difficult than ever today, New York state is proof that system-level change towards value-based care is possible. In 2011, amid a financial crisis, New York state leadership created the Medicaid Redesign Team to move the state towards 80% value-based payments by 2020. As a result of the program, the state has seen a 21% decrease in avoidable hospital use and more than 70% of managed care payments are now in value-based arrangements.

New York has set new precedent for what can be accomplished when value-based care is adopted across the system – and today many states are choosing to follow suit.

Establish Priorities: Protect the Vulnerable

Finally, when looking to improve value-based care programs during COVID-19, it’s paramount that healthcare leaders prioritize caring for our most vulnerable populations, including our elderly, minorities, veterans and non-English speaking populations. Tragically, nearly 35% of COVID-19 deaths have been residents or staff of nursing homes and African Americans are nearly three times more likely than white individuals to contract COVID-19. When implementing a value-based care strategy, healthcare leaders should ensure social determinants of health are integrated into their strategy, ensuring non-clinical factors such as patients’ access to transportation, nutritious food, social services and more are considered as part of quality care.

Let’s Come Together, While Apart

While these are three steps to bring value-based care to the forefront of healthcare, a common theme woven throughout is the need to work together. To share patient data amongst organizations, we must all work to comply with CMS mandates. Systemic change will only happen if every stakeholder in the healthcare system opts “in” to transformation for the benefit of patients. And, to protect our most vulnerable, we must align incentives across the continuum. Just as the pandemic has rallied healthcare to push through new, innovative tools for access and delivery, we must also take this moment to collaborate as an industry to propel value-based care into the future.

Michael Pattwell is the principal consultant of value-based care at Edifecs, a global health IT company. Pattwell works directly with health plans to operationalize software solutions that improve their data intake, analysis and utilization within their value-based care and payment operations.