AMGA: Advancing Value-Based Care Hinges on Claims Data Access

AMGA (American Medical Group Association) recently sent a letter to Congress outlining what it views as 2020’s top priorities for medical groups and health systems. Chief among the group’s recommendations was better claims data access for providers and patients in a value-based care world.

Congress and the administration have made it clear that how healthcare is financed and delivered must change in order to stop the unsustainable trajectory of healthcare spending and improve patient outcomes, which research has shown to be significantly worse compared to those in similar countries.

Value-based care models were designed to improve both spending and outcomes. The models incent lower cost, higher quality care by tying provider reimbursement to clinical and financial outcomes. But after nearly a decade of value-based care reform, providers are still struggling to implement the models successfully.

In the Jan. 31, 2020, letter addressed to House Speaker Nancy Pelosi, AMGA urged Congress to improve claims data access to advance the industry’s transition to value-based care.

“Access to claims data not only helps providers deliver better care, but it additionally empowers the patient,” the organization’s president and CEO Jerry Penso, MD, MBA, wrote in the letter. Patient access to claims data will result in “better conversations with their providers and subsequently lead to better health outcomes,” while it will also guarantee “more accountability between the provider and the payer regarding a patient’s care,” Penso explained.

Timely claims data sharing is integral to value-based care implementation and success, the letter continued, but AMGA members consistently cite access to administrative claims data as one of the top barriers to taking on financial risk for their patient populations.

“Knowing who provided care, what was done, when, and where a treatment was provided is critical for any value-based model to succeed,” Penso explained in a press release. “Without timely access to claims data, our providers simply won’t have a complete patient history and will be making care decisions with incomplete information.”

Requiring payers to share claims data with providers would be “a common sense solution to a problem that has stymied a broader adoption of value-based models of care,” he added.

Congress can ensure that providers and patients get the claims data access they need for value-based care success by including a provision in an upcoming healthcare legislative package, AMGA stated.

The organization worked with the Senate Health, Education, Labor and Pensions (HELP) Committee to include a commercial claims data-sharing provision within the Lower Health Care Costs Act from 2019. The provision required group health plans or payers offering group or individual healthcare insurance coverage to make commercial claims data available to patients and providers through application programming interfaces (APIs). The HELP committee passed a broader version of the bill, which is currently awaiting further Congressional consideration.

Building on claims data access, AMGA also recommended that Congress require all payers and providers to standardize data submission and reporting processes and harmonize quality measures across value-based care arrangements. Both are widespread problems for AMGA members implementing value-based care models with financial risk.

CMS has been working to improve claims data access. The federal agency launched Medicare Blue Button in 2010 to give Medicare beneficiaries access to Parts A, B, and D claims data through MyMedicare.gov. The federal recently launched an updated version of the initiative – Blue Button 2.0 – to enable beneficiaries to access the same claims and share it through APIs with select applications, services, and research programs.

CMS has also offered providers in certain Medicare value-based care models access to multi-payer claims data. Access to the data proved successful in a primary care-focused model, according to CMS officials.

But timely access to claims data remains a problem, especially when providers seek commercial claims data access. Health IT security events have also made better claims data access a challenge for many patients, providers, and payers. Requiring all payers to improve data sharing and standards, however, promises to unlock the key to advancing value-based care, according to AMGA and other key stakeholders.

To further advance value-based care, AMGA also recommended that Congress:

• Fully implement MACRA by eliminating exclusions from the Merit-Based Incentive Payment System (MIPS) and allowing for more alternative payment model participation through lower participation requirements
• Update benchmarking for accountable care organizations (ACOs) in Medicare value-based care programs to remove the ACO’s population from CMS’ regional adjustment calculation so organizations are not penalized for making improvements in its market and are not competing against themselves
• Reform the physician-self referral law to account for value-based care models and preserve access to advanced diagnostic imaging in the medical group setting by maintain the scope of the in-office ancillary services (IOAS) exception
• Promote access to telehealth services by creating a national standardized licensing and credentialing system
• Eliminate coinsurance payment requirements for services billed as chronic care management