Primary care physicians (PCPs) and other physicians continue to move away from the traditional fee-for-service (FFS) reimbursement model toward value-based, risk-based models of care that reward better outcomes and reduced health care costs. According to McKinsey’s projections, value-based care (VBC) contracts will cover nearly 65 million Americans, or 22% of insured lives, by 2025, up from 15% in 2021.
The trend towards VBC is clear. Yet, transitioning from a transactional, volume-based billing model to one that incorporates financial risk and patient health benefits is not easy. Successful implementation of value-based programs requires PCPs and physician groups to deploy technologies that provide complex hierarchical support for contract modeling, onboarding, data capture, digitization, payments, and exchange based on value. These technologies must also support social determinants of health (SDoH), quality reporting, and near real-time data synchronization between different parties.
A VBC network consists of multiple stakeholders which may include hospitals, physician groups, payers, risk entities such as accountable care organizations (ACOs), clinically integrated networks, social service networks, and community organizations (CBOs). Within these networks, there are many-to-many relationships in which an entity in a network may be engaged in multiple networks under various contractual commitments with other entities. An organization that provides nutrition intervention services, for example, may have contracts with health care providers under multiple VBC agreements. Such a “network of networks” can only work with an infrastructure that supports the hierarchies between these entities.
One of the major barriers to an effective VBC network is the inability of providers to integrate and manage a complex multi-party care network while meeting the event-driven and episodic demands of payment models that are no longer centered on claims. Another common obstacle is the inability of suppliers to obtain timely data reports and accurately forecast contract execution.
Enter value-based administration
A successful VBC contract modeler and reimbursement model facilitates stakeholder onboarding and data capture. Importantly, it also includes mechanisms to financially reward stakeholders for their roles. These mechanisms make the administration of funding pools, including the downstream distribution of funds and the exchange of data to participating partners, one of the most vital functions of value-based execution.
Traditional approaches and legacy systems, however, do not support the reporting relationship structures needed to integrate stakeholders into value-based contracts, creating a significant challenge for suppliers. Additionally, traditional approaches and legacy systems do not allow the scalability for the orchestration of cascading payment models (in which payer-provider collaborations integrate risky entities and downstream participating providers). This reduces the ability of providers to accelerate the adoption of various alternative payment models.
Such a hierarchical approach to onboarding partners, scaling contract operationalization, and sharing authorized data is essential to aligning the medical, social, behavioral, and environmental components of a governance-based administration. value (VBA) and high-performance networks that allow providers to treat the whole person while delivering care more efficiently and cost-effectively.
For providers to take full advantage of the relationships in a VBC network to provide better care at lower cost, four main components are needed:
Implementation of a robust cloud-based data infrastructure to enable clinical decision making, information sharing and real-time analysis
Realignment of downstream reimbursement to include both medical and non-medical providers (behavioral health services, addiction treatment centers, etc.)
Incorporation of SDoH resources and partners such as CBOs
Instrumentation of a dashboard on the real-time performance of all contracts along the way (as opposed to only at the end of the year)
The use of technologies such as artificial intelligence (AI) and machine learning is an integral part of an effective VBA data framework. These technologies allow systems to glean information and insights from the trove of big data collected and shared on the VBC network. Proper digitization of data across structured and unstructured data allows data to be interrogated in a way that yields valuable insights that can help physicians as well as all entities involved in the network.
By digitizing and correlating data to create a patient’s LHR (longitudinal health care record), providers can move from transactional processing to the outcome-based mindset needed for VBC. This requires the creation of a data infrastructure based on ontological mapping and proper digitization of semi-structured and unstructured datasets. This latter process helps to synthesize data sources of different types, resolve inconsistencies, help identify errors or misrepresentations, and seamlessly integrate credible new feeds.
Once the underlying robust data infrastructure is in place, a set of secure and scalable cloud microservices – on which different applications and integrations are built – can be deployed.
While a majority of vendor organizations already have technical infrastructures in place, these do not provide the adequate support for hierarchies nor the database layer of ontologies necessary for VBA.
Fortunately, it is possible for vendors to take advantage of technologies that support VBA without a pull-and-replace strategy. Achieving this requires a platform infrastructure to seamlessly integrate the data layers and then extend that data layer either as DaaS (data as a service) or as PaaS (platform as a service). as a service) so that partner companies or customers can use the existing applications served. via microservices or extend/create microservices and business applications for their own needs.
To deliver value-based healthcare, a unified view of the patient is imperative. A patient-centric LHR using the methodology described above enables easy sharing of data in an authoritative way and empowers physicians to provide timely relevant information for clinical assessment and decision-making – with a 360 view patient degrees.
The growing deployment of VBC models is driven by a common desire among providers and payers to improve patient outcomes while reducing healthcare costs. Values-based administration can support hierarchical needs between multiple entities involved in VBC. Coupled with an adaptive and scalable data and microservices infrastructure, VBA will accelerate the adoption of value-based healthcare.
Lynn Carroll is the COO ([email protected]) and Rahul Sharma is the Managing Director ([email protected]) of HSBlox, which helps healthcare players at the intersection of value-based care and precision health with a secure, information-rich approach to patient-centric, event-driven digital healthcare processes – strengthening overall health in traditional care settings, at home and in the community.