Value-based care puts health plans and health providers on the same team

June 29, 2017
By Andy Arends, Managing Director, Health Plans, NTT DATA Services

Most successes in creating better outcomes at lower cost are ones in which health plans and healthcare providers are on the same team, sharing risk and sharing responsibility for improving member/patient outcomes. The mechanism for successful collaboration has been well-designed value-based contracts that are mutually beneficial.

But even the successful teams in healthcare are still playing “single A” ball, and it’s time we all moved up to the big leagues.

Becoming teammates instead of frenemies

The new approach to healthcare as a team sport creates a radical change in the payer/provider relationship, moving away from past decades of competing for the same dollars. Many providers and health plans are still wary of changing their long-time frenemies into true friends and teammates. But it’s time to look to the future of healthcare. We really have no choice. If we don’t change the arc of healthcare expenses, the system will collapse under its own weight.

But there are lags and snags in the systems that make this transformation more difficult. To create the successful value-based contracts that put everyone on the same team, both payers and providers need better data. Too often, the systems supporting these teams are inadequate, unable to produce the shared, accurate, and comprehensive patient data necessary to support effective value-based contracts.

There are three major issues that health plans must address to get value-based contracting right, and they all have to do with data. There are many other issues, but these are the three most central to creating value-based contracts that hit the ball out of the park on outcomes and cost.

Identifying the high-value providers

Networks focused on high-value care must include primary and specialty practices that are patient-centric and focused on quality and cost. To maintain value and grow the network, you also need to help the other providers learn high-value methodologies. But how do you identify the high-value providers?

If you remember the book and movie “Moneyball,” data analyst Paul DePodesta helped the Oakland A’s identify players who could make the right contribution to the team. In 2002, the team had a 20-game winning streak that no one saw coming. The secret was the data and analytics that helped them put the right players on the team.

Most health plans don’t have a way of identifying the right players for their team. Most providers don’t have access to the data to benchmark themselves against their peers on quality and cost, making it difficult to improve performance.

Too often, health plans and providers are using manual reporting methods that make data acquisition and analysis slow and labor-intensive. Moving to fully automated systems that extract data at lower cost and effort will increase the speed and accuracy of data and give both providers and payers real-time insight into performance.

There are new vendors in the marketplace with systems specifically developed to close the data gap and allow more effective value-based contracts. At the recent AHIP Institute in Austin, I spoke with MediQire, whose value-based support system is currently in beta testing. It is a platform for effective sharing of clinical, claims, and socio-economic data critical to value-based success, allowing real-time understanding of physician performance and two-way data sharing that can improve performance.

Finding and closing the gaps in care

Health plans and providers both need comprehensive data on gaps in care, based on both claims data and clinical data from electronic health records (EHRs). By marrying these two data sets in a common platform, health plans will be able to identify patients whose clinical data demonstrates the need for care and can search the patients’ claims data to determine if patients are actually getting the care. Many times, providers prescribe but patients don’t follow through, and the provider doesn’t discover the gap until the next office visit. That can be months later. To close gaps in care requires real-time identification.

And once the gaps have been identified, both health plans and providers need a defined pathway for closing the gaps.

The good news is that there are vendors offering solutions to this problem. For example, Enli Health Intelligence CareManager platform integrates risk stratification, care coordination, and care delivery, connecting care teams and health plans in a way that brings insights and order to what has too often been a murky, chaotic process. Zeomega’s population health management platform does much the same thing. There are other vendors, too, offering platforms that integrate data and provide a pathway for closing gaps in care. If your health plan doesn’t have these capabilities, it’s time to invest.

Looking beyond the clinical and claims data

The most powerful influences on outcomes aren’t within the control of the traditional clinical approach to care. Too often, socio-economic factors derail patients’ efforts to improve their health. Factors such as lack of transportation, poverty, health illiteracy, and family difficulties need to be addressed to fix gaps in care. To do that, we need access to socio-economic data about patients and a way to organize and use that data.

That’s an important role for customer relationship management systems. Beyond just managing patient/member transactions, these systems now have the capability to organize socio-economic data critical to health, but for which there is no place in the EHR. These systems also allow for coordination with outside social services providers, allowing better communication and follow up.

Population health analytics are also starting to move toward integration of social determinants of health. Baystate Health, a large community-based integrated health system in western Massachusetts, is developing a new Population Health Risk Analysis system that uses clinical and socioeconomic data to give physicians a much better look at where resources are needed most. It is being developed as aproject through TechSpring, the Baystate Health Technology Innovation Center.

Data and collaboration is the path forward

For health plans looking to future success, focusing on better data and better provider relationships is key. To hit it out of the park on better outcomes and lower costs, two-way data sharing and collaborative relationships between health plans and providers will be critical.

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