Why a shift to value-based care needs to include a shift in organizational values and technology

By Gregory LeGrow | October 19, 2023


Prior to the pandemic, the transition to value-based care sputtered along like my high school car – a series of starts, stalls, and roadblocks. These were just as technical as they were cultural.

But when traditional operations came to a crashing halt, the entire healthcare ecosystem had proof that hinging success on volume versus outcomes needs crucial changing. We’re at a pivotal crossroads in that transition today. This requires more – not less work – but with the right people, process, and technology, the shift can reprioritize efforts from administrative burden to clinical success.

Where perception meets reality

The numbers speak volumes: 96 percent of payers believe alternative payment models (APM) result in better quality of care, and in the same Health Care Payment Learning and Action Network survey, 96 percent also believe APMs result in improved care coordination for patients. Payers who provided insights, however, also shared their thoughts around the biggest barriers to adoption of different payment paradigms: “provider willingness to take on financial risk” and “the ability to operationalize.”

Rightfully so. Providers spend 15 hours weekly, on average, trying to manually close care gaps and provide that evidence to payers. For small- or medium-sized practices especially, allocating those hours and other resources that could be spent scaling a business, after hours with patients, reading medical journals, or with family is an incremental hurdle. It’s no wonder provider burnout continues to proliferate.

We’ve entered a new era in which this is recognized on both sides of the table, however. Rather than a “Kramer vs. Kramer”-like battle over fee schedules, there’s an increasing interdependency among the leaders of the healthcare ecosystem. One of the most promising moves in the right direction is the recent introduction of a playbook generated together by the American Medical Association (AMA), AHIP (America’s Health Insurance Plans), and the National Association of Accountable Care Organizations (NAACOS). This new collaboration includes national and regional health plans, large and small physician practices, and ACOs, with the goal of building more participation in value-based care.

Danielle Lloyd, senior vice president of private market innovations and quality initiatives at AHIP, describes the output as a “cheat sheet to advance participation more quickly,” and improve quality and equity of care.

Quality data, and a quality experience

The chassis for the group’s initial recommendations? A “data-sharing ecosystem.”

This is surely more than access to all of the information, all of the time, but a curation of the right data in the right place – and the right ways and means of getting it there.

We’ve witnessed bionic prosthetics, operationalized virtual care, and can use 3-D printing for the operating room, but for far too long payment structures surrounding such innovations have been a tangled, manual mess. Emails, spreadsheets, proprietary portals as the primary means to determine care gaps or diagnosis gaps aren’t sustainable. The industry has progressed by leaps and bounds when it comes to addressing the patient experience as a consumerist one. Now, however, advanced tools and workflows are progressing payer and provider interdependencies and their user experience in a similar way. The results alleviate the burden of toggling between screens and tabs for a better clinical U/X and surface or flag what’s needed, when.

At New Jersey-based Summit Health, pre-visit chart preparation capabilities within the EHR have made more satisfied physicians – and healthier patients. “It really helps us close out those knowledge gaps, and those care gaps,” said chief quality officer Dr. Ashish Parikh.

Reporting out on more than 140 quality measurements to payers is increasingly more seamless. “We can see how well we’re doing, easily track data, and have it be sent to the payers in a structured fashion, or reported to payers,” he said.

Case [study] in point

A week before appointments, Summit Health clinical staff can review open gaps in care, like mammograms, eye exams, and A1c (HbA1c) hemoglobin tests for diabetes. Several types of gaps can be identified, and steps can be taken to try to close those gaps ahead of the visit. These include data gaps, to search charts for unstructured information like faxed documents to see if results can be found and then entered in appropriate structured fields to close those gaps. Summit also focuses on information gaps, with outreach to patients to determine if services have been completed outside of the organization’s network.

With previsit chart preparation, not only can care gaps be addressed ahead of the time, previsit documentation can be used to remind clinicians of concerns that a patient may want addressed at time of visit. Earlier access to information — and proactive reviews of that information — can curtail costs when care isn’t delayed or duplicative. It also enables clinicians to better understand patients and the care they need, supporting better compliance to value-based care contracts.

This is especially important as CMS puts more weight on the Consumer Assessment of Healthcare Providers and Systems survey, adding more pressure on plans to keep a high rating. The star ratings differentiate plans in a competitive marketplace – and determine the amount of quality bonuses plans can receive.    

Where perception meets reality for patients is getting even more complicated with a proposed rule for payers to advance interoperability and improve prior authorization processes. It advances other legislation requiring implementing an HL7 FHIR Patient Access API that requires including information about patients’ prior authorization decisions to help patients better understand their payer’s prior authorization process and its impact on their care. Besides patient data exchange proposals, the rule also includes a host of guidelines requiring payers adopt and maintain Prior Authorization Requirements, Documentation and Decision (PARDD) API, in an effort to more broadly share information across the continuum and reduce friction among its players.

Shifting toward population health for patients – and the entire ecosystem

As paradigms change, payers aren’t alone in their need to reevaluate allocation of time and resources. At Summit Health, what Parikh calls “a significant investment in population health” over the past decade includes technology to access and share data with payers, and a high-touch care coordination strategy. This includes a pharmacy team, social workers, and a quality group that tracks performance and makes outreach and education suggestions. Thanks in part to accessing payer data, care navigators generate lists of patients who are overdue for services and recommend outreach to bring them in. And care managers partner with primary care providers to perform patient outreach and make sure they understand and adhere to care plans.

Such collaborative and communicative approaches are models for other organizations, but need to be embraced sooner rather than later. The COVID-19 pandemic highlighted a severe need for greater health equity and a better focus on social determinants of health. Some of the larger payer players are leading the way. Elevance Health is working with NCQA and Harvard University to advance its health equity work, and Blue Cross Blue Shield recently announced Massachusetts’ first value-based contracts with incentives tied to equity.

The approach is, thankfully, more longitudinal than the point-in-time one that’s hamstrung healthcare for too long. The second planned playbook from AMA, AHIP and NAACOS will focus on payment methodology to support organizations’ financial health and sustainability. There’s little doubt that the guidance will place similar onus on a thriving data ecosystem and the tools that support it.