How to find success at the intersection of analytics and value
The transition from fee-for-service to value-based payments began as an effort to balance out the United States’ high healthcare spending with its disappointing national health statistics. The New England Journal of Medicine defines value-based care as “a healthcare delivery model in which…providers are rewarded for helping patients improve their health, reduce the effects and incidence of chronic disease, and live healthier lives in an evidence-based way.”
Value-based care ties the amount healthcare providers earn for their services to the results they deliver for their patients, such as the quality, equity and cost of care. Through financial incentives and other methods, value-based care programs aim to hold providers more accountable for improving patient outcomes while also giving them greater flexibility to deliver the right care at the right time.
The COVID-19 pandemic exacerbated and highlighted the need to focus on these five critical components, as it brought heightened attention to clinician burnout (nearly 63 percent reported signs of burnout at the end of 2021) and massive disparities in access to care, quality of care, outcomes, and affordability. The government and regulatory bodies have also played a key part in pushing the value-based care agenda forward with various initiatives (MACRA rule, Value Modifier program, etc.) incentivizing providers to shift away from fee-for-service.
This value-based performance and payment approach has shown signs of moderate success so far by reducing care costs and improving patient outcomes, as well as driving changes in readmission rates, avoidable ED visits, wellness visits, caregiver satisfaction and access to care.
Value-based care ties the amount providers earn for their services to the results they deliver for their patients. They need to strive for quality and equity at the lowest cost of care.
In value-based care arrangements, payers must monitor provider performance and member outcomes to manage provider contracts and negotiations.
Mutual key to success
For both payers and providers, succeeding with value-based care means working together to manage population health to improve clinical outcomes of a defined group of individuals through improved care coordination and patient engagement.
Without robust data—and an analytics engine that can handle it—organizations of all types and sizes have nowhere to start.
Though data collection processes have improved, there are still massive gaps in information needed versus information gathered.
Slow adoption of advanced technology and interoperability capabilities has also hindered healthcare organizations from using available data to inform their value-based care initiatives.
Value-based care initiatives are fighting an uphill battle against the disparities in care that are entrenched in the American healthcare system.
The transition to value seeks to remedy these issues and adopt a more equitable, whole-person approach to care. Though critically important, tackling inequity is no simple pursuit.
For all its problems, the fee-for-service model does offer a level of financial simplicity that providers especially appreciate.
Transitioning to value-based reimbursement fundamentally shifts the way a practice receives payment and adds intricacy to the contract negotiation process with payers.
The switch from volume to value requires commitment and patience, which can feel burdensome to clinicians who are already dealing with staffing shortages, competing priorities, and the threat of burnout. The industry has experienced significant cultural resistance to new reimbursement models.
Value-based care has huge potential—but that potential will only be realized if stakeholders across the industry are willing to work together.
Though the ultimate aim for all healthcare organizations should be health and wellness of patients/members, there are countless other operational objectives and financial pressures that can distract focus, drain resources, and derail efforts to collaborate.
Analytics play a critical role in advancing value-based care for a few key reasons:
Empowers data sharing
To succeed, providers need the ability to exchange information between disparate vendors with different interfaces and components. With this interoperability, they can see the full picture of patient and member behaviors and needs.
Establishes a 360-degree view of patients
When providers and care managers have a full picture of patient/member behaviors, trends, habits actions and socioeconomic data, they can make informed decisions to positively impact patient and member outcomes.
Integrates claims and clinical data
When previously disconnected data is brought together, it provides unique insight into health outcomes and costs of care. For example, it can be influential in avoiding medication errors and enabling an evidence-based approach to treatment.
Manage population health and risk
Understand where there are patient care gaps and high-risk groups to help target interventions and programs that improve patient outcomes.
Build high-performing provider networks
Efficiently monitor provider network performance to steer care to select providers, establish tiered-value networks, and improve contracting.
Assess provider quality and member outcomes
Measure and monitor provider performance to identify opportunities for improvements in quality, efficiency and costs
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