The goal in shifting from paying for volume to value-based care is simple: to align payers and healthcare providers around high-quality care that improves outcomes and lowers cost.

Operationalizing that shift, however, has proven more difficult for providers and payers alike.

Health systems are fragmented, and providers who participate in value-based care models take on increased accountability for care delivered outside of their practice – without a mechanism to coordinate that care effectively.

Only claims data

Payers, meanwhile, struggle to support providers in managing care for complex patients when their only consistently available source of information is claims data – often 90 days old by the time it is processed and requiring significant data-management and analytic capabilities for providers to use.

EHRs, meant to drive improved coordination between healthcare providers, have instead proven to be a source of provider burnout – and supplemental health IT has been only sporadically adopted, due largely to the fact that it cannot accommodate the inevitable variation in value-based models between payers, between commercial and government insurance, and so on.

This perceived complexity, exacerbated by provider concerns over independence, practice stability and financial impact, weighs heavily – and clearly highlights the need to bridge the gap between payers and providers.

"It’s important to offer not just a spreadsheet or graph, but rather a means to define specific, tactical actions that will help providers improve."

Doug Duskin, Equality Health

Equality Health is a health IT company that offers an approach to value-based care that bundles its shared provider-enablement platform, CareEmpower, with Practice Performance services designed to aid providers in achieving their goals.

CareEmpower is an EHR-agnostic system that provides a foundation for value-based performance by aggregating data to help providers better understand and manage their patient panel, and by tailoring practice workflows to align with value-based protocols that vary from payer to payer.

“It is well understood that providers are – and should be – heavily focused on patient care, and that time to manage administrative contract dynamics is therefore limited,” said Doug Duskin, president of HealthBI, a division of Equality Health.

“CareEmpower supports providers in managing their varied payer contracts to maximize value-based performance for both providers and payers. Further, available Practice Performance services help providers to improve quality, align with value-based principles, and understand how population-specific factors such as culture and language influence patient care and satisfaction.”

Actionable data

CareEmpower gives providers access to a longitudinal clinical history for each of the patients they manage. Payer data (claims, pharmacy data, and quality and coding gaps) provides the foundation for this patient history, but the system supplements payer data with real-time clinical information from EHRs and third-party clinical sources to give users a more holistic view of the member’s experience and facilitate timelier, more efficient delivery of care.

“Equality Health receives real-time admit and discharge notifications, updated member demographics, and clinical notes through longstanding partnerships with health information exchanges across the country,” Duskin explained.

“We also work with providers to implement real-time exchange of clinical data from their EHRs and third-party sources to augment the clinical history available from claims, streamline care coordination for complex patients, and maximize value-based performance; on average, Equality Health parses more than one million clinical documents through CareEmpower’s engine every year.”

Payer rule books

Having developed a comprehensive understanding of a provider’s panel, Equality Health leverages rules-based provider workflow to identify patients most in need of intervention given the provider’s value-based program participation and each patient’s risk profile, utilization and identified care opportunities, Duskin continued. Workflows and associated interventions are fully configurable and designed to align with value-based programs, he explained, but often include:

• Identification of patients needing a preventive visit.
• Identification of patients with open HEDIS gaps and unmanaged chronic conditions.
• Stratified, rules-based transitions of care workflow.
• Management of medication-related risks.
• Management of more complex care-management activities for high-risk members.

And CareEmpower’s real-time dashboard feature allows payers and providers to monitor the status of established rules-based interventions, and creates a direct connection between these interventions, patient outcomes and value-based performance; payer and provider views can be configured to facilitate shared accountability to established contract goals.

Bridging value-based contract performance metrics

The value-based care platform has been deployed to support approximately 14 million members nationally, Duskin said. As part of this coverage and experience, the following results are examples, he said, of bridging the value-based contract performance metrics:

• 19% HEDIS well visit improvement.
• 10% improved diabetic care testing.
• 25% reduction in 30-day readmissions.
• Decrease from 27 days to 4 days in post discharge follow-up time.

“In deploying technology to optimize value-based performance, integration with provider workflow is essential,” Duskin advised CIOs and other health IT leaders. “It’s important to offer not just a spreadsheet or graph, but rather a means to define specific, tactical actions that will help providers improve.

“Further, the ability to connect these actions with their effect on contract performance will maximize trust and improve adoption of value-based care models,” he concluded. “The shift to value-based care is critical in improving patient outcomes and reducing healthcare costs – and leveraging HIT to optimize the shift to value-based care is the key to making both providers and payers successful.”

Twitter: @SiwickiHealthIT
Email the writer: bill.siwicki@himss.org
Healthcare IT News is a HIMSS Media publication.