Lynn Carroll
Creating an infrastructure to support value-based care
July 01, 2022
By Lynn Carroll and Rahul Sharma
More than a decade after the passage of the Affordable Care Act, value-based care (VBC) is gaining momentum as providers and payers seek to improve patient outcomes while gaining control of runaway healthcare spending in the U.S. According to the latest Alternate Payment Model (APM) Measurement Report by the Health Care Payment Learning and Action Network (HCPLAN), 40.9% of U.S. healthcare payments flowed through two-sided risk payment models in 2020. Furthermore, an overwhelming 87% of health plans surveyed believe APM activity, including value-based contracts, will grow in the coming years.
The long-term success of healthcare providers and payers hinges on making a successful transition from traditional fee-for-service (FFS) payment models to VBC. Making VBC work, however, requires the ability to reimburse all participants in a VBC network for their services. And therein lies the challenge.
A VBC network first must have an infrastructure that ensures data can be shared by participants upstream and downstream, which may necessitate a technology investment to free up traditionally siloed data and capabilities. Second, a VBC network needs to accommodate a large variety of evolving payment methodologies that fall under the VBC label, each of which may have different incentives, performance metrics, and payouts. The spectrum currently includes shared risk arrangements such as accountable care organizations (ACOs), bundled payment programs, full and partial capitation, and the Medicare Shared Savings Program with upside and downside risk.
Finally, providers and payers, i.e., whomever holds financial risk, increasingly recognize that social determinants of health (SDoH) play a huge role in health outcomes and healthcare cost management. VBC networks must be able to integrate nonmedical and community-based organizations (CBOs), and in doing so, enable them to share SDoH and other data, offer services, and play their roles in the joint care coordination plan.
The data sharing and payment allocation required for VBC cannot be supported using legacy claims and clinical workflow systems designed for FFS. Successful administration of VBC programs requires a fundamental change in infrastructure.
Ontology mapping, longitudinal health record vital to VBC
Creating an infrastructure to support effective value-based administration starts by extending critical existing legacy systems to enable many-to-many relationships between VBC stakeholders and their counterparts, including insurance carriers, ACOs, clinically integrated networks, primary care, social service networks, CBOs, and more. This effort requires digitization as well as co-relation of data to create a Longitudinal Patient Record (LHR) to support outcomes-based reimbursement decisions, as well as the reporting of VBC contract performance.
Central to this initiative is a data methodology based on ontology mapping. An ontology encompasses a representation, formal naming and definition of the categories, properties and relations between concepts, and data and entities that substantiate one, many, or all domains of discourse. Whereas changing data properties in a traditional relational database is a time consuming and complex task, requiring wholesale deletion and re-creation of property tables, a database built on ontological languages can easily be modified after the fact by making simple changes to the concept.
There are 18 different ontologies patient data can fall into, including immunity tests, disease registry, demographic data, claims and remittance data, pharmacy data, clinical data, DNA/genome data, SDoH data, and more. Furthermore, all this data needs to have an underlying Enterprise Master Patient Index (EMPI) to link the datasets to the right patient.
Proper digitization of not only structured and discrete data, but also semi-structured and unstructured data is also necessary to enable VBC. This process makes it possible to synthesize data sources of various kinds, address their inconsistencies, and incorporate new feeds, enabling the needed analysis and forecasting for outcomes-based VBC. This underlying data infrastructure is then exposed via a set of secure and scalable microservices on which different applications and integrations are built. This approach delivers a unified view of the patient and creates an LHR for easy data-sharing in a permissioned manner.
What value-based administration looks like in practice
When executed successfully, an infrastructure designed for value-based administration coordinates the “many-to-many” relationships between VBC stakeholders and their ecosystem attributes to enable information capture and sharing, necessary B2B and B2C multichannel communications, and full execution of required financial arrangements. A core capability of this approach is the upstream management of funding pools and downstream distribution of monies to VBC network partners – doing so in alignment with the wide range of disbursement models in play within the given network.
Here’s an example: transferring money to a home-dialysis provider for full payment after documenting receipt of the required post-visit status report for a patient, while simultaneously paying a Meals on Wheels community provider upon receiving confirmation of food delivery for the same patient. Diverse, high-performance networks enable both medical and non-medical resources to fulfill their respective roles within a diverse plan of care, using the same technology rails. That’s value – and that’s administration.
Conclusion
VBC is transforming healthcare using a whole-person, proactive approach that considers SDoH and leverages incorporation of services provided by community-based organizations. To effectively implement VBC, it is essential that payers and providers manage complex contractual relationships between network partners in a way that ensures all participants are paid. This requires a change in infrastructure that incorporates ontology mapping and digitization of both structured and unstructured assets to create an LHR that serves as the foundation for data exchange and outcomes-based VBC.
About the authors: Lynn Carroll is the chief operations officer and Rahul Sharma, the chief executive officer of HSBlox, which assists healthcare stakeholders at the intersection of value-based care and precision health with a secure, information-rich approach to event-based, patient-centric digital healthcare processes – empowering whole health in traditional care settings, the home and in the community.
More than a decade after the passage of the Affordable Care Act, value-based care (VBC) is gaining momentum as providers and payers seek to improve patient outcomes while gaining control of runaway healthcare spending in the U.S. According to the latest Alternate Payment Model (APM) Measurement Report by the Health Care Payment Learning and Action Network (HCPLAN), 40.9% of U.S. healthcare payments flowed through two-sided risk payment models in 2020. Furthermore, an overwhelming 87% of health plans surveyed believe APM activity, including value-based contracts, will grow in the coming years.
The long-term success of healthcare providers and payers hinges on making a successful transition from traditional fee-for-service (FFS) payment models to VBC. Making VBC work, however, requires the ability to reimburse all participants in a VBC network for their services. And therein lies the challenge.
A VBC network first must have an infrastructure that ensures data can be shared by participants upstream and downstream, which may necessitate a technology investment to free up traditionally siloed data and capabilities. Second, a VBC network needs to accommodate a large variety of evolving payment methodologies that fall under the VBC label, each of which may have different incentives, performance metrics, and payouts. The spectrum currently includes shared risk arrangements such as accountable care organizations (ACOs), bundled payment programs, full and partial capitation, and the Medicare Shared Savings Program with upside and downside risk.
Finally, providers and payers, i.e., whomever holds financial risk, increasingly recognize that social determinants of health (SDoH) play a huge role in health outcomes and healthcare cost management. VBC networks must be able to integrate nonmedical and community-based organizations (CBOs), and in doing so, enable them to share SDoH and other data, offer services, and play their roles in the joint care coordination plan.
The data sharing and payment allocation required for VBC cannot be supported using legacy claims and clinical workflow systems designed for FFS. Successful administration of VBC programs requires a fundamental change in infrastructure.
Rahul Sharma
Creating an infrastructure to support effective value-based administration starts by extending critical existing legacy systems to enable many-to-many relationships between VBC stakeholders and their counterparts, including insurance carriers, ACOs, clinically integrated networks, primary care, social service networks, CBOs, and more. This effort requires digitization as well as co-relation of data to create a Longitudinal Patient Record (LHR) to support outcomes-based reimbursement decisions, as well as the reporting of VBC contract performance.
Central to this initiative is a data methodology based on ontology mapping. An ontology encompasses a representation, formal naming and definition of the categories, properties and relations between concepts, and data and entities that substantiate one, many, or all domains of discourse. Whereas changing data properties in a traditional relational database is a time consuming and complex task, requiring wholesale deletion and re-creation of property tables, a database built on ontological languages can easily be modified after the fact by making simple changes to the concept.
There are 18 different ontologies patient data can fall into, including immunity tests, disease registry, demographic data, claims and remittance data, pharmacy data, clinical data, DNA/genome data, SDoH data, and more. Furthermore, all this data needs to have an underlying Enterprise Master Patient Index (EMPI) to link the datasets to the right patient.
Proper digitization of not only structured and discrete data, but also semi-structured and unstructured data is also necessary to enable VBC. This process makes it possible to synthesize data sources of various kinds, address their inconsistencies, and incorporate new feeds, enabling the needed analysis and forecasting for outcomes-based VBC. This underlying data infrastructure is then exposed via a set of secure and scalable microservices on which different applications and integrations are built. This approach delivers a unified view of the patient and creates an LHR for easy data-sharing in a permissioned manner.
What value-based administration looks like in practice
When executed successfully, an infrastructure designed for value-based administration coordinates the “many-to-many” relationships between VBC stakeholders and their ecosystem attributes to enable information capture and sharing, necessary B2B and B2C multichannel communications, and full execution of required financial arrangements. A core capability of this approach is the upstream management of funding pools and downstream distribution of monies to VBC network partners – doing so in alignment with the wide range of disbursement models in play within the given network.
Here’s an example: transferring money to a home-dialysis provider for full payment after documenting receipt of the required post-visit status report for a patient, while simultaneously paying a Meals on Wheels community provider upon receiving confirmation of food delivery for the same patient. Diverse, high-performance networks enable both medical and non-medical resources to fulfill their respective roles within a diverse plan of care, using the same technology rails. That’s value – and that’s administration.
Conclusion
VBC is transforming healthcare using a whole-person, proactive approach that considers SDoH and leverages incorporation of services provided by community-based organizations. To effectively implement VBC, it is essential that payers and providers manage complex contractual relationships between network partners in a way that ensures all participants are paid. This requires a change in infrastructure that incorporates ontology mapping and digitization of both structured and unstructured assets to create an LHR that serves as the foundation for data exchange and outcomes-based VBC.
About the authors: Lynn Carroll is the chief operations officer and Rahul Sharma, the chief executive officer of HSBlox, which assists healthcare stakeholders at the intersection of value-based care and precision health with a secure, information-rich approach to event-based, patient-centric digital healthcare processes – empowering whole health in traditional care settings, the home and in the community.