By Josh Hetler, Executive Vice President, Sales & Marketing, DataLink
Given the precipitous decline in elective procedures and other nonessential care due to the COVID-19 pandemic, and as many hospitals and private provider practices struggle financially with significantly fewer patient visits, the limitations of fee-for-service models have never been [1] Industry experts believe that post-pandemic, the shift toward value-based contracts will continue. Organizations making this shift are moving carefully and thoughtfully, building systems that encompass quality benchmarks and risk adjustment rules.[2]
As an alternative and potential replacement for fee-for-service reimbursement from private payers or government programs, value-based care gives payments to providers based upon measures, such as quality, efficiency, cost and positive clinical outcomes. The incentive is to focus upon improved long-term patient outcomes vs. the volume of treatments.
Stakeholder alignment is critical for value-based care, especially as payers focus on the cost and impact on population health and assume accountability for delivering better patient outcomes at a lower overall price. To offset the potential profit decline, stakeholders should consider partnering with a healthcare technology company with expertise in population health and a track record for empowering better outcomes using real-time data aggregation, EHR and health information exchange (HIE) connectivity and quality reporting through dynamic data visualization.
Focus on Pandemic’s Impact
Providers
It will be critical for providers to adopt effective tools that will enable them to identify care gaps, access data that informs clinical decisions, improve quality and risk adjustment scores and improve patient outcomes. Unfortunately, the data required for understanding the quality of the care being delivered to patients during this pandemic has been largely unavailable.
This situation underscores how the current approach to quality and safety measurement remains too labor intensive, often causes substantial data delays and lacks sufficient standardization to allow for rapid data sharing. Payers need to have the ability to systematically collect information from providers or patients with the aim of assessing the quality of care provided to improve performance, treatment outcomes and efficiency.
Quality Measurement
The pandemic environment has also highlighted how quality measurements fail to deliver information that can inform decision making where it’s needed most—at the point of care. Many claims-based quality measures, such as the Patient Safety Indicators, have a 12-month lag between the end of the care delivery period and the reporting to hospitals on their performance.[3] Even non–claims-based measures, such as hospital-acquired infection measures, have long delays. For feedback to work it must be timely. What’s more, this prolonged delay makes the information less actionable and, during a health crisis, the delay is magnified, eliminating the significant opportunity to learn and improve.
Currently, defined performance measures that could help to understand how, for example, telehealth has affected the quality of care delivered to patients is non-existent.[4] Access to a rapid tool for identifying and disseminating a standardized way of collecting data about new types of clinical information enables health systems to understand and improve performance.
HEDIS® Measurement Reporting
Healthcare Effectiveness Data and Information Set (HEDIS®) measures are used by 90% of health plans in the country for health care performance measurement. These measures are critical to the overall healthcare system because they ensure that payers are collecting and analyzing data as it relates to their performance. In fact, a number of payers started using value-based reimbursement models to help meet HEDIS benchmarks.[5]
The COVID-19 pandemic, however, has impacted this data collection activity. The newly released guidance eliminates the requirement for Medicare Advantage (MA) plans to submit HEDIS 2020 data (for 2019 dates of service), because of the burden placed on health care workers. Instead, CMS says it will use last year’s performance (measure-level rates and ratings, based on 2018 performance) for the 2021 Star ratings.
Finding the Right Technology Partner
The best point-of-care solution effectively identifies open care gaps for proactive closure and provides payer-agnostic data to inform clinical, quality and risk adjustment programs for improvements in quality, risk adjustment scores and patient outcomes.
It’s also important to find a solution with a robust HEDIS engine that is certified by the National Committee for Quality Assurance (NCQA) for all measures for 2020 and refreshed annually for the most accurate data. Such a solution can facilitate the transition to value-based care by meeting the need for a complete interoperable population health management solution that aligns the payer, provider and patient with one solution that proactively closes care gaps, ensures visibility into the patient’s complete health status and manages utilization in a way that facilitates better care planning and improved health outcomes.
Through the aggregation of data from EHRs, HIEs, claims, labs, pharmacy and hospital sources, users gain transparency at the patient-level and provider-level through real-time data visualization that drives collaboration opportunities to break down departmental silos across the organization. The inclusion of supplemental data, such as a retinal eye exam or blood pressure measurement, provides additional clinical information about a member for a more comprehensive picture of the care and services delivered.
Ultimately, effective value-based care taps into meaningful data and technology applications to efficiently manage patient-centric care that results in improved outcomes and lower costs. A value-based model with high-touch, prevention-focused care is about providing more care that is holistic now to prevent the need for far more expensive care later.
[1] Muchmore, Shannon. COVID-19’s public health crisis could also be a financial disaster for hospitals. Healthcare Dive. April 8, 2020. https://www.healthcaredive.com/news/covid-19s-public-health-crisis-could-also-be-a-financial-disaster-for-hosp/575638/; accessed October 29, 2020.
[2] Hagland, Mark. One Foot In the Boat, One On the Shore: A Scenario Suddenly Made More Complex. Healthcare Innovation. May 28, 2020. https://www.hcinnovationgroup.com/policy-value-based-care/value-based-care-quality-measurement/article/21140064/one-foot-in-the-boat-one-on-the-shore-a-scenario-suddenly-made-more-complex; accessed October 29, 2020.
[3] Austin JM, Kachalia A. The State of Health Care Quality Measurement in the Era of COVID-19: The Importance of Doing Better. JAMA. 2020;324(4):333–334. doi:10.1001/jama.2020.11461; https://jamanetwork.com/journals/jama/fullarticle/2767747; accessed October 29, 2020.
[4] Austin, 2020.
[5] Gruessner, Vera. Payers Could Boost HEDIS Quality Measures by Exchanging Data. Health Payer Intelligence. Aug. 16, 2016; https://healthpayerintelligence.com/news/payers-could-boost-hedis-quality-measures-by-exchanging-data; accessed October .
