Efficient Data Sharing Needed for Value-Based Care Transition

The COVID-19 pandemic changed how healthcare organizations approach care delivery, but the industry needs more efficient and transparent data sharing methods to accelerate provider transition to value-based care models.

Providers and payers alike are increasingly moving away from fee-for-service and shifting toward value-based payment models, which reimburse providers based on the quality of care they provide rather than quantity.

Value-based care models allow providers to expand care delivery and offer services that may not be traditionally reimbursed under fee-for-service models, such as providing transportation services to facilitate care access, according to Lynda Rowe, senior advisor of value-based systems at Intersystems.

However, this transition is not entirely simple for hospitals and healthcare providers.

“It’s a very big change, especially for providers, and people often overlook the changes in workflow, the changes in thinking, the changes in organizational structure, how you think about care for patients; that’s very different under this model than it was under fee-for-service,” Rowe told RevCycleIntelligence in a recent interview.

To be successful under a value-based care model, organizations must ensure they have the proper resources and staff to execute this care management and coordination. Additionally, providers must consider financial risk.

Some value-based care models have an upside risk-only structure, in which providers receive shared savings if they remain under budget and lose nothing if they go over budget. But according to Rowe, successful value-based care models need to have upside and downside risks.

Under two-sided risk models, providers must accept accountability if they exceed their benchmark and compensate the payers for a portion of the losses. This presents a significant financial risk for providers, Rowe pointed out.

Data sharing is one of the most significant barriers to value-based care for providers.

“Under HIPAA, you can only share data for treatment, payment, and operations, and it has to be specifically on a need-to-know use-case basis,” Rowe explained.

“So, for a payer to contract with a provider around value-based care, it actually means they have to change their data use agreement to make sure that all the data they need to get from the provider to help them will come in their direction and vice versa,” she added. “The payer needs to be able to share back cost and utilization information in a timely manner which, by the way, for a payer is incredibly hard to do.”

Inefficient data sharing leads to delayed feedback from payers, which can cause problems for providers. Rowe, who sits on the board of a federally qualified health center (FQHC) participating in a Medicaid accountable care organization (ACO), noted that they didn’t know if they made or lost money in the model until 18 months after the year ended.

“One of the issues is that this data sharing has got to be faster, more transparent, and it’s got to be done in a way of trust, and that’s something I always ask about and talk about when I’m talking to payers and providers,” Rowe shared. “How do you change the discussion to be about this tension between: you’re a payer and all you care about is lowering your cost and you’re a provider and all you care about is making a lot of money?”

The key is to focus on sharing information in a way that primarily benefits the patients and their health outcomes. Interoperability is key to optimizing data sharing and achieving success under value-based care models, Rowe contended.

Providers must have timely access to data to understand if they are within budget and, if they are not, what is putting them over budget. Providers also need feedback from payers to understand their progress toward meeting quality measures.

“The way interoperability has worked for a long time is getting that in a timely manner has always been incredibly difficult,” Rowe noted.

Communication between providers and payers can be a potential solution to overcoming the barrier of current data sharing methods. Most payers base their data on claim systems, which may not have a paid claim for up to 90 days after a care episode—a contributing factor to the delay in data sharing.

“If the provider organization now says, ‘Oh, well, I’ll share with you clinical information, and you can integrate that clinical information with your claims information,’ they now actually have more insight into what’s happening and whether the goals of those quality measures are being met, whether the encounters are ticking in at the right level, and they can provide that feedback in a more timely manner,” Rowe explained.

Communication between hospital systems can also help organizations choose a suitable value-based care model—another critical aspect for seeing value-based care success.

Not every value-based care model will work for every care setting, Rowe indicated. But looking at the common conditions and characteristics of patient populations can help hospitals and provider organizations select a care model that will work for them. Talking to other similar hospitals about value-based experiences can also help provide insight, Rowe added.

While data sharing inefficiencies remain a barrier to value-based care, Rowe emphasized that hospitals and provider organizations operating under a fee-for-service model should transition to value-based models. At some point, the models will not be optional, Rowe pointed out.

“Organizations have to start on that trust journey, start on thinking internally about how they’re going to get there, not how they’re not going to get there because there are some organizations that are still just fighting it,” she said. “The fighting it part is not helpful.”

“Sometimes that takes a leadership change to make that happen. And that’s not something that’s going to happen overnight, but if you have enough internal leaders that say, ‘We need to start thinking and organizing ourselves,’ because in the end, this is the best way you should be thinking about treating patients,” Rowe concluded.