Posted January 16, 2017 by Adele Allison
For health plans, payment reform brings new opportunities to collaborate more fully with providers. As payers and providers modernize reimbursement towards population-based payment, the data requirements and optimization needs become ever greater. In a population-based payment model, payment and risk are shared across the provider community based on the collective care and health of the patient. Before providers can culturally embrace new value-based payment models, a technical infrastructure is needed to address growing complexities in data and operational considerations. A value-oriented collaboration can best be achieved with a step-by-step data sharing process.
Step #1 – Payers share data with providers: Providers recognize their need for greater transparency into care gaps. Payers can help meet this need by sharing data and analytics with providers. Quality measures should be reported to show the view at the aggregated population health level and at the individual patient level. Examples of measures include hospital readmissions, emergency department use, blood pressure and eye screenings for those with diabetes, and dispensing of controlled medication for those with asthma. Analytics to evaluate measures such as these will help providers identify performance trends and specific gaps for intervention and medical precision at the patient point.
Step #2 – Providers give data to payers. To strengthen the fabric of trust between the payer and provider network, the next step requires providers to reciprocate data-sharing with their health plans. This creates complexities in operations. If you have a network with providers sitting in traditional fee-for-service arrangements, before you can move to performance-based reimbursement, they too must have the right people, processes, and technology to capture, analyze, and understand data. Introducing a medical home incentive program into performance-based payment contracting is a classic example of working to modernize provider infrastructure. This model heightens awareness of the value of data for improved performance against quality measures, wellness and preventive care, and management of chronic disease. Medical homes also require providers to establish a regular cadence in data review for ongoing performance improvement with the patients they serve.
Once data is being collected, health plans should seek to augment provider-reported information through pay for reporting initiatives. Health plans can begin rewarding providers to electronically transmit information to the plan. CMS has been in the pay-for-reporting business for years under the Physician Quality Reporting System (PQRS), initially launched in 2007. However, once again, automated reporting requires the proper technical infrastructure to operationalize.
Step #3 – Payers move to global payment across a care continuum. As providers begin to pay attention to data and metrics, plans can begin to move with the provider network to alternative payment models (APMs) that use a fee-for-service architecture. Here the goal is to introduce payment models across a care continuum, rewarding providers collectively for outcomes linked to certain performance standards and operational efficiencies. For example, bundled payments for procedures that include the acute episode and a defined post-acute period compel historically disparate providers to work together. Hospitals, surgeons, and rehab providers will coordinate care for targeted quality outcomes and shared economic rewards. Initially such cost containment strategies may have providers sharing in the upside only. As the provider ecosystem matures, downside risk can be added.
Step #4 – Providers contract for upside and downside risk. Eventually, the goal is to migrate to comprehensive population based payment. Models may be condition-specific or global based upon an attributed patient population. Plans may capitate a network of providers for diabetes management, for example, or they may introduce a global payment covering comprehensive care across a defined population. Regardless, quality performance and outcomes always factor into the reimbursement equation.
A mutually collaborative, respectful relationship between health plans and providers can emerge as they collaborate more fully on common goals of value-based care. Technology and data sharing will be a key determinant in the success of this changing relationship.
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The views expressed in this publication are solely those of the author and do not necessarily reflect the position or policy of DST Systems, Inc. or its affiliates, subsidiaries, joint ventures, officers, directors, or management.