Payers, Providers Need Data to Talk Value-Based Care

The definition of value is evolving, and so are the capabilities needed to support the transition to value-based care, industry experts recently shared at Xtelligent Healthcare Media’s Payer+Provider Virtual Summit: The Return to Value.

From the Triple Aim to the cost versus outcomes equation and right place-right time-right care paradigm, payers and providers have struggled to find a common definition of value. This misalignment has broken down many conversations between the two sides about value-based care.

But if there is a silver lining from the recent COVID-19 pandemic, it is a greater interest among payers, providers, and other healthcare stakeholders to work together to ensure the delivery of highly valuable care.

“We need to work with the delivery system, both clinically and socially, to provide the resources to treat, and I think talking about some of that, the back and forth, starts to align, one, the definition of value, and two, the bigger thing, which is how we get there together,” Caraline Coats, vice president of provider alliances at Humana, said during a panel discussion.

In the early days of value-based care, industry stakeholders were focused on achieving clinical and financial metrics, Coats explained. But as value-based care models have matured, so have the measurements to include metrics around social determinants of health and other factors that play into treating patients holistically.

Co-panelist David Hatfield, MD, employs a similar philosophy at Hatfield Medical Group where he serves as chief medical officer. At his practice, value is not only about lower costs and better outcomes, but also quality patient experience and provider well-being. And to achieve this “Quadruple Aim,” team-based care is necessary.

“I can't stress enough that in order to enter into this world of value, where we really want to lower cost and have better outcomes, and we like to say getting the patient the right care at the right place at the right time, is really centered around a team of folks, and to me it begins and ends with chronic care managers and coordination,” Hatfield stated.

Hatfield Medical Group leverages a team of chronic care managers to build relationships with patients to ensure they can manage diabetes, high blood pressure, and other conditions appropriately, both within the healthcare system and beyond it.

But the group also uses a population health team, primary care providers, the front office, back office, specialists, and even payers to coordinate holistic care that addresses everything from outcomes and costs to experience and provider-patient relationship.

“The payers are part of our team,” Hatfield asserted. “They help us to identify patients that maybe have fallen through the cracks and that we need to either go meet them at their home or do more outreach to get them in the clinic more frequently. Anybody that touches or talks to a patient is part of our team really.”

To support this level of care coordination and team-based care takes a lot of data though.

“It's some of the gaps in their abilities, especially the smaller, independent practices, to have the tools to analyze the data and how they're performing,” added Mike Albainy, founder and CEO of MDClarity, a healthcare software company. “Their systems generally aren't even designed for these paradigms. They are very much a transactional-based system. How do I get out a claim? Not, how do I look at an episode of care? Or how do I track the overall health, clinical, and financial relationship with this patient?”

Providers need data analytics tools to understand the value of the care they deliver and establish a strategy for providing value-based care for every patient, Albainy continued.

However, payers can also do a better job at sharing their wealth of patient information with providers to improve value, Coats stated.

Humana, for example, has focused on addressing food insecurity – a major social determinant of health – during the pandemic. The payer identified members who are food insecure and not necessarily in the traditional sense. Some members were scared to leave their homes out of fear of contracting COVID-19, so outreach teams were formed to address the root causes of food insecurity and identify specific needs.

“We have an opportunity to better share that with our providers to collectively outreach and try and find out what’s going on,” Coats stated.

A good data strategy can help move this along, according to Albainy.

“It's all about really having a good data strategy, including getting some data from the payer and automatically integrating your data from all your different systems and maybe some of the data you're getting from the payer to build workflows and make decisions around that,” he said.

With more integrated data, the healthcare industry may be able to move to a more ideal definition of value that really centers on the patient.

“Somebody's notion of a good outcome might be very different from some very technical, clinical measure built somewhere,” Albainy stated. “It might just be, ‘Hey, I want to be able to go on a walk around my neighborhood again without feeling pain.’ We've strived to figure out a way to show value when a patient is comparing where to go for some treatment or episode of care, not just the pure cost, but what is the quality of this provider versus that provider and look at the overall value.”

Hatfield Medical Group and Humana are also aiming to deliver similar results to patients by providing physician scorecards, member satisfaction scores, and other data points around patient experience. But at the end of the day, the experts agreed that value-based care is evolving and how stakeholders leverage team-based care, data analytics, and other capabilities will depend on how their value-based care models define value.

Humana, for example, has a wide range of value-based care models that help providers along the continuum, from upfront care coordination fees attached to quality metrics to providing more automated capabilities and risk-sharing agreements for providers with larger panels.

“Start with helping financially initially, and growing that and sharing data and figure out what's working and not, and if we grow together we can be successful, and that just takes time and trust,” Coats stated.