ocus Area Roundtable on Next-Generation Value-Based Payment Programs

Value-Based Payment Programs – Highlights from Recent Roundtable

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Like other systemic changes needed to ‘fix healthcare’ in the United States that have been proposed, discussed, and tried in various forms and fashions over the last 20 years, the widespread, meaningful adoption of value-based payment programs seems to always be just a few years away. And now, the coronavirus pandemic has forced all healthcare stakeholders to re-think what is needed to truly transform the healthcare delivery system in the United States. In our first Focus Area Roundtable on Next-Generation Value-Based Payment Programs, participants discussed obstacles to value-based payment programs, selecting and measuring quality measures and outcomes, and topics related to engaging stakeholders – particularly payers and providers – collaboratively and in a proactive vs. reactive manner.

HCEG’s Executive Director Ferris Taylor and Eileen Lee, VP of Product – Connected Solutions, at Zelis Healthcare, helped facilitate discussion among roundtable participants: leaders from health plans, health systems, care provider organizations, and two consultants serving the healthcare industry. This post presents highlights of the roundtable. Individuals involved with transforming their provider reimbursement and payment systems are welcome to join our Focus Area Roundtables including the 2nd roundtable on Next-Generation Value-Based Payment Programs.

Obstacles to Wider Adoption of Value-Based Payment Programs

Ferris kicked off the roundtable by asking participants to share their thoughts on what obstacles are hampering the increased adoption of value-based care and payment programs.

Eileen Lee shared her perspective that many smaller, regional, commercial health plans simply don’t have the infrastructure or the resources to change the framework for how they process payments. She noted that with current infrastructures built around making fee-for-service payments (FFS) and high costs associated with implementing and administrating both FFS and value-based payment programs, the opportunity for these types of organizations to evolve is simply not available to them.

Expanding Provider Networks and Accessing Data in EHR’s

Obstacles to Value-Based Payment

A chief technology officer of a health plan stated that their commercial plans still operate predominantly in a fee-for-service model and that they face two challenges in expanding their value-based payment footprint: developing their value-based provider networks and getting hospitals to participate and being able to connect into provider EHR systems to be able to send messages back and forth to support inpatient wellness and preventative health activities.

Eileen questioned whether engaging providers to participate in value-based programs was related to providers being unwilling to accept risk or whether they didn’t want the additional burden associated with collecting and reporting data.

One participant working with the front-line of care delivery shared that a big challenge for the front-line – from a value-based program’s perspective – is that collecting program metrics is ‘just another thing to do.’ She noted that if new data collection requirements can be better integrated into daily activities and workflow, value-based programs would be better accepted – particularly by physicians.

RELATED: Will Administrative Cost of Independent Dispute Resolution Force Providers to Join Networks?

Dealing with Different Requirements from Multiple Payers

In response to this comment on fitting into clinician workflow, Eileen reminded the roundtable that each payer has its own requirements and processes that clinicians must adhere to. The roundtable acknowledged the importance of recognizing and addressing payer-specific requirements, using standards and common definitions to the greatest extent possible, and selecting easily adaptable processes across multiple payers.

Capturing Meaningful Metrics as Part of Doing Business as Usual

One participant shared that, from his perspective, some Accountable Care Organization’s (ACO) are so concentrated on maximizing revenue by focusing on meeting quality measures and reporting end of year metrics, that innovations in care are not really welcomed. He noted that many metrics used for value-based programs should be captured and reported as a normal course of providing patient services – not just because they are required to receive specific payment program incentives.

The ability to incorporate data like laboratory values, medication lists, patient surveys, and other data that does not rely on inputs from clinicians or payers to support new payment models is one consideration noted in roundtable discussion.

Total Cost of Care Essential to Execute Value-Based Payment Programs

One participant associated with providing post-acute care in the home noted that the ability to accurately measure the total cost of care is key to being able to execute its value-based payment programs. She claimed that they don’t have access to all the data needed to be able to calculate the total cost of care.

Eileen asked if she thought that some of the transparency and coverage rule mandates will make calculating the total cost of care easier. The participant noted that they may if they were able to get eligibility data feeds to understand benefit coverage but obtaining that data is still up to the health plans to decide whether or not to share that data.

Measuring Quality, Outcomes, and Cost for Value-Based Payment Programs

Ferris asked the roundtable to share their thoughts on measuring quality, outcomes, and cost for value-based payment programs.Next-Generation Value-Based Payment Programs. Quality measures. Cost of Care. Outcomes.

One participant noted their plan’s success with a value-based contract on heart failure using pharmaceuticals. He explained that what makes that agreement work is that it can be measured. They know when people take their medication whether it works for them or does not work for them based on claims data and information easily reported by the physician. And they have a very measurable outcome. He went on to say that costs savings can be measured using claims data.

Another participant, a manager of clinical integration at a regional, integrated healthcare provider/payer system, asked participants if it was possible for value-based care program outcomes to be measured with claims volume alone. And could a program be deemed ‘better’ due to the ability to measure its outcomes based on claims data alone without other patient artifacts in order to determine the quality of outcomes?

A health plan CIO stated that claims data alone is not enough in almost all cases and that clinical data is needed as well. Another person added that benchmarks are also needed to know how you’re performing relative to some baseline.

How the Pandemic has Impacted Value-Based Payment Programs

Eileen from Zelis questioned the group on how the pandemic has impacted value-based care. She noted that at the beginning of the pandemic, providers that were participating in value-based care and payment plans had a little bit less of an impact from the drop in service volumes. But now that patients have spent a year delaying care, Eileen wonders if providers are or will be seeing more negative outcomes even while they (physicians) are still providing the same historical level of care.

Providers Anticipating Increased Risk Due to Pandemic-Induced Delays to Care

Eileen went on to share observations on two trends emerging since the pandemic started in Q1 of 2020. She stated that there has been an increase in interest among providers in value-based care and value-based payments as a way to ward off the negative impacts of fee-for-service when patients stopped coming; noting providers see value-based payment programs as a leveling – a way to help manage their risk and keep their cash flow moving.

She added that she expects data to reveal the same trend about preventive care and about the severity of illness coming into ER’s that others are seeing. And wonders what that may mean for long-term outcomes and the measurement of those outcomes for purposes of value-based care payment. Eileen noted that it may be more difficult for physicians to get incentive payments and show high-quality metrics if their patients simply don’t participate in the care gap closing activities that they need to participate in order for there to be quality care outcomes. Listen here for pandemic’s impact on adoption of value-based payment programs [00:38:34 – 00:40:01]

Managing Patient Migration Outside the Network – Incentivizing Collaboration

One participant shared that supporting the ability of their network physicians to collaborate and communicate with other network physicians – and incentivizing them to do so – has had a large positive effect on both total cost of care point and outcomes relative to patient’s risk profile and chronic conditions: fewer ED visits and readmissions to inpatient care.

In line with comments made by Eileen Lee about the decrease in preventative services since the pandemic began, this participant noted that managing this so-called ‘migration outside the network’ has been hampered by the decrease in preventive care services utilized by many plan members and patients since the start of the pandemic in Q1 of 2020.

Other Considerations on Capturing Metrics and Improving Outcomes under Value-based Payment Programs

Participants shared insights and observations on other ways to capture metrics and improve outcomes under value-based payment programs – particularly as more and more services are moving from traditional acute care settings to community and home-based settings:

Delivering Care in the Home and Use of Remote Monitoring Technologies

One person noted seeing opportunities created for digital startups, especially remote patient monitoring startups where organizations can outsource some of the patient monitoring part and then receive great insights from these new companies only when it is needed. Listen here for more on new opportunities for supporting value-based payment programs [00:31:25 – 00:32:56]Delivering Care in the Home and Use of Remote Monitoring Technologies Challenge in Accessing and Capturing Outcomes Data in the Home – Alleviated by OASIS Data

Challenge in Accessing and Capturing Outcomes Data in the Home – Alleviated by OASIS Data?

Building on the idea of diagnosing, monitoring, and providing care in the home, Ferris asked one participant, a provider of post-acute services in the home, how they are capturing measures and outcomes data in the home care environment and whether that data is captured in an EHR.

The participant shared that, ideally, the delivery of home-based services would be integrated with EHRs but to do that they must obtain provider by provider approval to get access to providers’ EMR’s. She shared that another way they are looking at getting data is to try to get access to the Outcome and Assessment Information Set (OASIS) data because that is standard across all home health providers. She noted that using the OASIS data requires a technology solution to receive the data, integrate it into their technical architecture, and be able to manipulate and trend the data.

Impact of FHIR-Based Use Cases on Value-Based Payment Programs

Next-Generation Value-Based Payment Programs. Quality measures. Cost of Care. Outcomes. Technologies. FHIR. CDS Hooks. MessagingOne participant asked whether use cases based on the FHIR – the foundational standard to support data exchange via secure application programming interfaces (API) – would have a positive impact on value-based care programs. The CTO mentioned previously noted that integration of Smart on FHIR-based apps running on a provider’s EHR would be a positive step toward obtaining data needed for value-based payment programs.

He also mentioned the use of new standard messaging and data exchange tools between payers and providers that utilize ‘CDS Hooks.’  Unfortunately, while the standards exist, leveraging them is still a one-on-one approach necessitating working with a FHIR vendor and integrating the back-and-forth integration.

While Ferris noted CMS’s Interoperability and Patient Access Final Rule now in effect as an example of a positive data exchange development between healthcare stakeholders, Eileen clarified that 67% of Americans are covered by self-funded or TPA plans that are not subject to the rule.

RELATED: Balancing Amount of Data Shared with Providers – Increasing Impact of Value-based Arrangements

Closing Thoughts on Next-Generation Value-Based Payment Programs

Ferris asked Eileen Lee of Zelis to wrap up the roundtable by offering a closing comment. Eileen shared that the adoption of value-based payment programs is one of those scenarios where the problem is easy to see and the solution seems even easier to decide but implementing it is complicated due to the diverse and diffuse environment of healthcare in the United States.

Listen here to Eileen Lee comment on the movement to Next-Generation Value-based Payment Programs [00:44:40 – 00:45:40]

Share Insight & Opinion on Value-Based Payment Programs and Join Our Next Roundtable

To assess payment-related challenges payers and providers are experiencing, identify gaps in the current payer-provider payment system, and help determine what’s holding back the adoption of new payer-provider payment solutions, the HealthCare Executive Group has created a mini-survey on Payer-Provider Payment Solutions. Healthcare stakeholders are urged to complete this three-minute survey. All survey respondents can receive survey results and be entered into a drawing for one of four $25 Amazon gift cards.

Join our next roundtable on Next-Generation Value-Based Payment Programs on Thursday, November 18, 2021, at 2:00 PM ET where additional insight, real-world experiences, and the latest developments on value-based payment programs will be discussed.

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‘Next Gen’ Data Strategy, Architecture and Technology to Achieve Innovation & Growth

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marklogic ahip institute Operationalize Before You Analyze: Innovation and Growth Powered by DataMany of our sponsor partners participated in the 2017 AHIP Institute & Exhibition in Austin, Texas earlier this month – sharing info on their healthcare products and services; and sharing information via informal and formal presentation sessions.

Bill Fox, VP of Healthcare and Life Sciences of our sponsor MarkLogic, moderated a panel titled “Operationalize Before You Analyze: Innovation and Growth Powered by Data.” The panel of business and technical leaders discussed how they have used “next gen” data strategy, architecture and technology to achieve innovation, growth and modernization results.  Panel members included:

Sunil Godbole, Senior Director, Application Development at Aetna Inc.

Glen Schuster, Consultant, former CTO at Centene Corp

Shahran Haider, Managing Director of Enterprise Data Strategy and Analytics at L.A. Care

Analyzing Data and Operationalizing Data Are Not the Same Thing

Bill Fox began the panel discussion by offering that analyzing data and operationalizing data are not the same thing and that many health care organizations have focused their innovation and growth investment on the “shiny ball” of analytics — the end stage of the data journey — instead of first improving the agility and speed at the beginning “operational” stages of the data journey.

Save Time on Operations – More Time for Innovation

Glen Schuster: “When companies try to do operations and analytics at same time, it’s operations that almost always ‘wins’”

Sharan Haider: “Now is the time to innovate. And to do that, organizations have to free up time and iterate through faster execution cycles that add more value to operations while improving member and consumer experience.”

Sharan Haider: “If we shorten the amount of time needed to get data together, we can innovate and do analytics better and faster.”

Flexible, Secure, Multi-Model Database Systems are Key

Bill Fox: “Next generation systems must be able to provide users with what they want, how they want it, and when they want it. Data can’t be siloed across numerous legacy systems but must be virtualized in a multi-model database capable of supporting multiple data models against a single, integrated back end where structured and unstructured data in multiple formats are all supported by a flexible and secure infrastructure.”

Glen Schuster: “Value-based reimbursement and managing risk demand that healthcare firms deal with their legacy architecture and employ the resources necessary to facilitate change. Data is classically under reported. A company that can gather data and improve its quality will be in a better position to manage its risk and gain a significant competitive advantage.”multi-model database data models integrated backend structured unstructured marklogic hceg ahip institute

Rapid Implementation with Proven Business Case

Glen Schuster: “It’s easier now to create a hard dollar business case for operationalizing data. Do you know where your data is? How difficult is it to collect, combine and operationalize your data? Over-analyzing cost vs. worth can be an unproductive conversation.”

Sharan Haider: “I know I have a problem. I come to conferences and get excited at what I see. But I’m also a realist. I need to be able to implement solutions from my point of view. To be able to collect, merge and manage my data better and faster.”

Sharan Haider: “We are working to develop a 360 view of our provider customer service, appeals and grievances data in 4-6 weeks. What was a long-term pain and seemed unsolvable was suddenly doable.”

Centers of Excellence and Scaled Agile Framework

Sunil Godbole: “We had an impossible data problem and started our journey 2 ½ ago. We strive to make whatever we build with reusable assets. We established a Center of Excellence (COE) and got the best resources available on market. Our COE performs governance, builds frameworks (ex. Logging, alerts, ingest and egress methods, etc.) that we can extend to all lines of business, affiliates, and other data centers.”

Sunil Godbole: “Code quality has to be present. We employ a Scaled Agile Framework (SAFe) and consistently enforce its use. We do brown bags with scrum teams, new developers and business stakeholders to maintain and grow our skills based and data agility-focused culture.”

Learn More About Healthcare Innovation & Transformation

For more insight and ideas on digitally transforming your healthcare operations and analytics, check out our sponsor partners and consider following the Healthcare Executive Group and our sponsors on social media.

Change Healthcare –> @Change_HC
Cumberland Consulting Group –> @CumberlandCG
GuideWell Connect –> @_GWConnect
HealthEdge –> @HealthEdge
MarkLogic –> @MarkLogic
McKesson –> @McKesson
Softheon –> @Softheon
Virtual Health –> @VirtualHealth_

An Executive Leadership Forum at GuideWell Innovation Center

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Executive Leadership Forum at GuideWell Innovation Center hcldr hitsm innovationOur Executive Leadership Forum held at the GuideWell Innovation Center on Monday, May 8th was attended by 21 healthcare executives and solution provider thought leaders. The three-hour event – titled Operationalizing Before Analyzing: Healthcare’s Modern Journey Powered by Data – focused on some of the underlying challenges and issues regarding how healthcare data and analytics technologies impact consumers, providers and health plans.

The forum included lively discussion on real world use cases for healthcare data and analytics, a demonstration of live 3D interaction possibilities and a tour of the GuideWell Innovation Center. The forum was capped off by a happy hour for participants to network with each other and forum sponsors: MarkLogic and Intel.

In this post, highlights of the discussion between forum participants and key takeaways will be presented. In future posts, an overview of the 3D interaction demo and tour of the GuideWell Innovation Center will be shared.

HCEG Board Chair Ferris Taylor shared some information on the tour of the GuideWell Innovation Center and Live 3D Collaboration in this post on LinkedIn.

Demand for Real-time Data and Transactions

A lot discussion during the forum centered around current complexities and how demand for real-time data and transactions—across clinical, administrative and financial operations–is increasing exponentially every day and putting significant demands on service model / operations and legacy infrastructure, which are mostly batch / file transfer oriented.  Several issues were identified as current concerns:

  1. Many underlying data challenges
  2. Lack of agility in quickly responding to opportunities
  3. Inadequate data governance/provenance with ETL approaches in the legacy data pipeline

All audience members agreed they wanted faster time to market and better ability to respond to clients / market / regulations and be more agile when it comes to data. There was broad agreement that “data integration” is a journey that should follow a new data integration pathway instead of the legacy Extract-Transform-Load (ETL) approach:

Real World Use Cases

Over the course of the discussion there were a number of data capture and analytics use cases shared between forum participants. One use case described enrollment data submitted to the IRS on the 1095-B Health Coverage forms sent to individuals noting their qualified health coverage during each month in the year.

One participant described how the IRS had reported back to the health plan that 40% of the records submitted by the health plan to the IRS had errors in name, social security number and/or dependent status; basic required enrollment data elements that the plan was not able to validate or authenticate during the initial enrollment process and remained that way throughout the entire year. Garbage-In-Garbage-Out.

This “1095-B use case” elicited feedback from one forum participant having recent experience at the Census Bureau with the participant describing how government agencies often don’t have complete, accurate data. Just because CMS might have data of one quality level, they don’t always share that data with related agencies so the IRS or the SSA or state Medicaid administrators likely have different data.

Leverage All Data Types & 3rd Parties

Forum participants shared unique perspectives and a Q&A ensued on the example of how the Census Bureau uses associated data to significantly improve the timelines, accuracy and overall value of census data by editing it against 3rd party sources.  This Census Bureau use case and another use case described by forum participants of a BCBS plan emphasized that 3rd party data sources and unstructured data are very important to service improvement, member/patient experience, innovation and growth-oriented project investments.

Primary Investment Areas: Data Improvement & Integration Projects

Forum members identified the following investment areas for data improvement and integration projects that healthcare executives may implement over the next 12-18 months to modernize healthcare data and applications:

healthcare-data-integration-investment-areas-ELF-Blues-MarkLogicThought Leader Presentations

This Executive Leadership Forum was co-sponsored by MarkLogic and Intel. The information shared by these two sponsors are made available here:

    “Healthcare ‘Next Gen’ Data Projects”Bill Gaynor, U.S. Healthcare Director – MarkLogic, Inc.

    “Intel Healthcare Security Readiness Program Overview”Joan Hankin – Global Director of Marketing & Business Development – Healthcare & Life Sciences at Intel Corporation

In addition to information shared by MarkLogic and Intel, Constance Sjoquist, former Research Director at Gartner, also participated:

    “Disrupting the Status Quo in Healthcare” – By Constance Sjoquist, Chief Content Officer – HLTH, LLC.

Three Basic Tenets Unanimously Agreed

At the end of the forum, participants unanimously agree on three basic tenets:

  1. Complete and accurate data – especially basic demographic and social determinants – MUST begin with the first member/consumer/patient-provider interactions at the point of service
  2. Data needs to be authenticated, validated, verified and ENRICHED against other sources – then normalized across other supportive partners and their ‘systems of record’
  3. Today’s technology can support the capture, validation and use of healthcare data on a relatively inexpensive basis.

Join Other Healthcare Leaders

For more information on the Healthcare Executive Group and how you can become more ‘in the know’ and effective as a healthcare executive or thought leader, check out this information about becoming a member. You can also follow us on Twitter, friend us on FaceBook and follow us on LinkedIn.

Operationalizing Before Analyzing: Healthcare’s Modern Journey Powered by Data

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Operationalizing analyzing data in healthcare organizations innovation programsOperationalizing data and analyzing data are not the same thing. Some healthcare organizations have made the painful and expensive mistake of focusing their innovation programs and growth investments on the “shiny ball” of analytics – the end stage of the data journey – instead of first improving the agility, speed and quality of the initial “operational” stages of the data journey: combining, enriching, indexing, searching, harmonizing, and alerting data. When it comes to operationalizing data and using information to help run the business, healthcare organizations must not fail to address numerous data silos, point-to-point integrations and other significant data-related challenges exacerbated by the lack of enterprise features such as security, transactional support, performance, and governance.

An Executive Leadership Forum Event

On Monday, 5/8/17 at 3:00 to 5:30 pm EDT, healthcare business and technology executives will meet at the GuideWell Innovation Center (Orlando, FL) to hear from healthcare business and technology leaders who’ve used “Next Gen” data concepts, strategy and technology platforms to fuel their industry innovation programs and digital transformation. This special healthcare executive leadership forum event is hosted by the Healthcare Executive Group (HCEG) and supported by HCEG’s sponsor MarkLogic and Intel. The event is open to all HCEG members and healthcare leaders, is free of charge and will be followed by a networking happy hour reception. Attendees of the 2017 Blue Cross Blue Shield National Summit may find this forum to be a great way to leverage their attendance at the Blues Summit.Healthcare Executive Leadership Forum at Guidewell Innovation Center

Who Should Attend?

Any healthcare executive with mission critical projects that require improved data agility and faster time to delivery should consider attending this unique leadership event:

  • Business Executives (operations, administrative, clinical) responsible for business “digital” modernization & improving experience / satisfaction initiatives.
  • Technology Executives (integration, architecture, infrastructure, development, security) charged with implementing and supporting operational and analytical data integration platforms to achieve business goals.healthcare executive leadership forum event - national blues summit orlando florida

What Business Executives Will Take Away

  • More insight into the competitive advantage and cost-savings a 360-degree view of Anything – member/patient, provider, etc. – can bring to a healthcare organization.
  • How creating profiles / preferences enhance engagement and experience while improving Net Promoter Scores (NPS).
  • Understanding of the business advantages and opportunities associated with ‘Next Gen’ data architecture and technology.
  • An understanding of use cases that increase business agility and improve time to market.
  • How continuous security, governance and sharing of data that’s usable and actionable is key to enabling growth and innovation.

What Technology Executives Will Take Away

  • An understanding of modern, multi-model “platform” approaches for integrating disparate data silos into a single operational and analytical infrastructure (secure, ACID compliant, etc.).
  • Awareness of the landscape of data technology vendors offering data platform solutions.
  • Why standalone, point solution “apps” or data “tools” present significant vendor lock-in risk.
  • How a metadata search approach supports rapid enterprise integration of structured and unstructured data.
  • Better understanding why top national healthcare organizations are implementing “Next Gen” data hub Centers of Excellence (CoE) to power their innovation programs and digital transformation.

More on Healthcare’s Modern Journey

For more information on leading the modernization and transformation of healthcare in 2017 and beyond, consider joining the Healthcare Executive Group and following us on our digital channels: Facebook, LinkedIn and Twitter. You can also subscribe to our bi-weekly newsletter.