The transition from a fee-for-service healthcare model to value-based care (VBC) in the U.S. has continued to gain momentum in the wake of the Covid-19 pandemic. That’s because providers operating on a fee-for-service basis saw revenue fall sharply through much of last year as elective procedures were cancelled and many patients delayed primary care, even for chronic conditions. Quite simply, under the traditional healthcare payment model, no service equals no pay.
In contrast, those providers with risk-based contracts were paid a specific amount, either per member or per patient, regardless of whether that patient received healthcare services. It doesn’t take a CFO to recognize that something is better than nothing. Nor does it take the Surgeon General to know that a reimbursement model which rewards providers for delivering quality care while controlling costs will produce better outcomes for patients, providers and payers. That is the promise of VBC and risk-based payment models.
For many providers, however, there’s a major stumbling block preventing them from adopting VBC and alternative payment models – the lack of timely and actionable data. VBC and risk-based contracts focus on preventative medical care and wellness, while “whole person care” adds to the care equation by including the mental and emotional well-being of a patient or member.
Caring for the whole person means understanding the connection between physical conditions (such as diabetes and congestive heart failure) and behavioral health components. This knowledge empowers providers, patients and payers to develop comprehensive and effective care plans.
Yet without the proper tools to collect and analyze patient and claims data – including social determinants of health (SDOH) such as a patient’s socioeconomic status, housing security and access to food, medications and transportation – it is extremely difficult for providers to be proactive.
To care for the whole person requires an understanding of whether a plan member or current patient has access to such things as fresh fruits and vegetables, an Uber ride to a routine doctor’s appointment, enrollment in a smoking cessation program, or a social support network to assist with the long-term effects of Covid-19. Indeed, during the height of the pandemic there was a spike in demand for behavioral health and substance abuse treatment services as millions of Americans struggled with depression triggered or exacerbated by fear, isolation and economic anxiety.
Amazingly, many providers still are relying on Excel spreadsheets to track wide-ranging quality and claims data for various care models. These immense data sets quickly become extremely difficult to access in a timely manner. Even in traditional data warehouses, there is no way to efficiently integrate aggregate data; one has to go in and actually hard code such reports, which can take months to achieve.
In addition, different health systems have varying levels of sophistication. They may have data, but they don’t really understand what the data is telling them or the best action to take based on the information. Or decision making is hampered because the available data is not current, and sources of data are siloed and hard to aggregate.
The only way to manage hundreds of measures for different types of healthcare contracts is with advanced analytics. You can’t take action on a population of patients unless you can view the data through different prisms, such as chronic disease, SDOH and behavioral health. To do that you need analytics that turns data into useful and actionable information.
Analytics allow providers to significantly improve the quality of care they deliver because they are equipped with actionable insights, such as when a patient was last tested for a specific condition or whether a patient is adhering to prescribed medications. With a preventative, whole-person approach, patient care is enhanced, preventable high-cost episodes of care such as emergency room visits and hospitalizations are minimized, and healthcare costs are lowered.
It’s no surprise, then, that analytics can help providers and payers collaborate more effectively to reduce healthcare costs. For payers, analytics eliminate the long lag time for claims data. And while clinical data is often more up to date, making the information available to any provider that delivers care to a member or patient can be a daunting challenge.
Ideally providers need both clinical and claims data. The claims data tells you where patients have obtained healthcare services so that a health system knows that a patient also saw an unaffiliated specialist – which is valuable for clinicians seeking to treat the whole person.
Which leads back to the fundamental benefit of VBC: Better outcomes and lower healthcare costs through a proactive and holistic approach to member and patient care that also informs population health. Imagine having all that patient and claims data in a health information exchange (HIE), with multiple health systems contributing data. It would allow for a view of patients and populations across a large metropolitan community. It all begins with data.
But data isn’t information. Analytics is what turns data into information about patients and populations of members. Applying analytics to integrated data, including SDOH, allows providers and payers to improve quality of care through value-based models and effectively manage financial risk.
For healthcare organizations eager to embrace advanced analytics as a pathway to VBC, here’s some advice to consider:
- First, managing risk using analytics is not a consulting project. Hiring “experts” to analyze where you may be underperforming from a risk perspective may seem like a good idea, but once those consultants leave, you’re no longer getting fresh data. Providers and payers need the ability to self-monitor through analytics so they can generate ongoing insights into clinical and financial performance.
- Second, an advanced healthcare analytics platform cannot be treated as an IT project. It is a business initiative intended to solve a complex business challenge. Thus, you need input and buy-in from stakeholders across an organization’s business functions. You also need a user-friendly interface that makes it easy for clinicians and care managers to access and manipulate data.
- Finally, take advantage of newer technologies such as the cloud to put a robust solution in the hands of clinicians and care managers so they can proactively manage their member and patient populations. Advanced analytics-as-a-service is a highly scalable and reliable delivery model.
Value-based healthcare requires technologies that measure, predict and improve services based on medical and behavioral data, including SDOH. Such tools empower providers to deliver better outcomes that demonstrate value. By embracing flexible healthcare analytics solutions that measure and analyze across different data sources and promote a holistic approach to healthcare delivery, providers are better positioned to drive value-base care success.