How to Meet Value-Based Care Demands
By Shashi Padarthy, Cristina Crespo, and Catherine Shih
For The Record
Vol. 27 No. 6 P. 8
The health care industry is undergoing a radical transformation from volume-based care to value-based care (VBC). As a result, VBC models such as accountable care, bundled payments, and pay for performance have overtaken the industry. According to a study by Availity, more than 75% of health care providers currently participate in at least one value-based payment model. By 2016, VBC is expected to drive one-half of all health system revenue. Furthermore, Health & Human Services recently set a goal to have VBC account for 50% of all Medicare provider payments by 2018.
In essence, VBC programs align financial incentives to performance as measured by the Healthcare Effectiveness Data and Information Set (HEDIS), which charts patient satisfaction scores, cancer screenings and immunizations, controlled prescription drug use, and the management of common chronic conditions. These models drive hospitals, health systems, and physicians to provide high-quality, cost-effective care.
Success in this new business terrain means health systems utilizing VBC models must reimagine how to collectively engage patients, providers, and practices to increase collaboration and participation across the continuum of care; use technology to improve the quality of and access to care; aggregate data from health plans, clinical systems, and practice management systems; and use analytics to provide actionable intelligence prospectively and at the point of care.
3Ps: Patients, Providers, and Practices
Traditionally, multiple caregivers are involved in a patient's health and wellness across multiple sites of service, making the practice of health care inherently social. Practice, physician, and patient engagement, or 3P engagement, is key to not only improving performance on quality metrics but also the successful redesign of care delivery. Roadblocks to improving VBC performance generally are caused by services and/or tests not being provided, being documented incorrectly, or not being billed. This often can be traced back to either patients being unaware they need a service or test or unable to make appointments, or physicians being unaware that a service or test was needed during the most recent visit. VBC performance typically improves when the 3Ps are engaged.
Successful VBC contracts can be achieved only with the support of those who interact directly with the patients and deliver care: practices and physicians. There are numerous ways to foster clinician-patient engagement, including embedding care managers in clinics and introducing field-based care navigators who can guide patients through the care continuum. Building patient relationships helps close gaps along the care continuum and ensures compliance with prescribed therapy.
Additionally, it's important to provide clinical education and documentation on standards of care while delivering actionable intelligence to practices. This helps practices proactively identify patients who have visits scheduled and determine which services are outstanding.
Care coordination is another effective method to reduce the total cost of care. Although it may seem relatively simple to educate physicians and embed care managers into clinics, problems can arise. For example, it may be difficult to change provider behavior to ensure education is retained and operationalized and care managers are viewed as team members. Change management planning is required to ensure improvement efforts have enough impact to improve HEDIS measures.
Traditionally, patients have navigated the complex health care system on their own.
Noncompliance with provider directives has been perceived as being caused by patients' lack of awareness or understanding of how to manage their care. However, under VBC, health systems are not rewarded for merely offering screening tests or recommending wellness visits. Instead, the focus has shifted to outcomes. Now, rewards will be issued only for cases in which patients follow through with the screening test or wellness visit.
As such, contact centers can be valuable tools to boost the efficiency of appointment scheduling. Contact centers directly engage patients at the start of their health care experience, providing a seamless telephone call to reduce appointment cancellations and no-shows, leading to improved VBC performance.
Social, Mobile, Analytics, and Cloud
3P engagement requires all health care constituents to have access to the right information at the right time, delivered via their device of choice. Health systems must focus on not only data collection but also on analysis—the interpretation and effective presentation of seemingly disconnected data.
The ability to view a patient's record anywhere and at any time via an EHR is transformational. However, the technology is only the foundational layer of a new paradigm shift.
New IT architectures driven by social, mobile, analytics, and cloud technologies, known as the "SMAC stack," deliver advanced software to address the VBC needs. SMAC technologies are not meant to be bolted to existing business processes. Rather, the intent is to create systems of engagement to transform the business model itself.
Digital health information is flowing constantly from every computing device via health apps on mobile phones, wearable biometrics, insurance portals, and so on. Culling meaning from this blanket of invisible energy dubbed a Code Halo—the digital information that surrounds everyone—can create unprecedented levels of value and improve VBC performance.
To prevent information overload, providers require actionable insights that allow them to easily sort through and identify health risks, close care gaps, and provide more personalized care. Better data lead to better insights, improved decision making, and more empowered patients and providers. In fact, the translation of these intricate Big Data matrices into pointed insights will be the real differentiator when it comes to operating in a VBC environment.
To ensure a seamless experience for all constituents—patients, providers, and practices—a VBC technology platform must accomplish the following:
• aggregate longitudinal data from EHRs and health information exchanges;
• integrate with relevant nonclinical information from social media and devices such as wearable biometrics, remote monitoring, apps, and telemedicine systems;
• translate data into actionable insights;
• present information understandable by clinical and nonclinical care teams; and
• deliver insights anywhere and anytime through mobile devices and the cloud.
Paying attention to the complete ecosystem and how each component interacts with patients is essential to improve VBC performance. Successful health care companies will be those that leverage new technologies to transform their businesses and provide enhanced experiences for patients, providers, and practices alike.
— Sashi Padarthy, the senior director of Cognizant's health care consulting practice, advises providers, pharmacies, and pharmacy benefit management companies on topics such as regulatory compliance, accountable care models, and performance improvement.
— Cristina Crespo and Catherine Shih are both senior consultants with Cognizant's health care practice. Crespo has helped design and implement care management programs and technical solutions for various risk-bearing entities while Shih focuses on population health management, including the implementation of new payment models.