Three Essentials Providers Need for Risk-Based Contracts

Largely unbeknownst to the public, a tremendous innovation in healthcare is unfolding: value-based care. As the former president of population health at Cleveland Clinic, I’m excited about a model of care that can lower the cost of healthcare and move the needle on patient outcomes. But I’m also a realist, albeit an optimistic one.  I will readily admit that to date, value-based care has been easier to practice in the hospital-the “mother ship,” so to speak, where sophisticated monitoring capabilities are calibrated to quickly alert of potential problems and care teams are on hand to intervene.

The outpatient setting is a different story altogether. Here real-time data is not so forthcoming, and communication with other care team members not at all seamless. Indeed, care “teams” typically don’t extend outside of the hospital, but rather, disperse into different providers operating in different spaces. So, for value-based care to work in the outpatient setting-in other words, to work at all-these persistent challenges need to be overcome.

An emerging trend among payers like United and Aetna is to equip the providers in their networks with shared technology tools and services to do just that. Let’s be clear on the value to payers for doing so: a new ability to comprehensively assess and adjust risk conditions and to improve quality outcomes. Although these shared offerings can vary by contractual and health plan needs, they generally include the following three key assets:

• Actionable data from a shared platform.

Time and again, providers cite lack of access to the right data as the primary reason they can’t scale population health management. And no wonder-there is no single source of data that provides the entire picture of patient health, or identifies which patients are at highest risk, or which care activities are needed to prevent acute events at a later point.

EHRs have some valuable data, but not all that is needed. And even for the data EHRs do provide, the vendors charge an exorbitant sum to extract. HIEs theoretically offer affordable access to important information such as hospital admits, but connecting to them is still an IT project for many providers. As for getting payer claims data, historically that has been as difficult for providers to obtain as it has for payers to acquire certain data from providers.

With all this in mind, many payers are equipping providers with a technology platform that aggregates data from claims (from multiple providers), HIEs, data from the provider’s EHR (minus the need for an expensive integration), and other sources. Using these platforms, providers can:

• Identify high-risk patients and their care gap

• Pull lists of actionable care activities to close these gaps

• Receive alerts of health events, like hospitalization, so providers can act in time to connect patients with follow up care

• Coordinate care plans with other providers and track the progress (this is especially powerful for integrating behavioral and physical healthcare-another important emerging trend)

• Access at any time a comprehensive picture of patient health; foundational knowledge for practicing comprehensive healthcar
  
  2.  Provider engagement.  

Providers can’t use these platforms in a bubble. Practicing comprehensive, proactive care is a relatively new paradigm, even if one providers have longed for years to practice. Extracting lists of preventative care activities, tracking their progress, and proving such quality efforts are all new processes for many providers.

Here payers are taking measures to set providers up for success. While it’s not financially feasible to send a performance specialist to every provider’s office, they can assure that every provider has access to knowledgeable support services via call centers staffed by experts. These services can span from support in using the technology platforms to identify high risk patients to coordinating care plans with specialist providers.

3.  Proof of quality.

Providers are busy and need reminders when their quality work is due. And here again, payers can’t send performance auditors to every provider location to manually collect and analyze chart data. To that end, payers can assure that support services extend to helping providers report and prove their quality work.

Note that given the advances being made in machine learning and other AI technologies, we can expect that quality data reporting will eventually be a fully automated process, saving providers and payers even more time. We’re not quite there yet…but it’s coming.

Conclusion

Value-based and pay-for-performance contracts hold the key to bending the upward trajectory of healthcare costs, but they can sabotage the provider’s profitability in the absence of actionable data and support for this new model of reimbursement. Rather than let that happen, payers, health plans, and other organizations have an opportunity to help these providers succeed.

In summary, this includes equipping providers with tools that facilitate shared data and care planning; technical support for feeding and watering of these new shared systems; and provider engagement to facilitate true practice transformation. With these new macro elements in place, the entire healthcare ecosystem is set up for success.

Scott McFarland is president of HealthBI where he leads the organization’s population health technology platforms and contact center solutions for provider and payer organizations.