How tech can successfully empower value-based administration

For organizations to thrive in value-based care arrangements, they’ll need a specific set of technology to inform delivery choices.

Healthcare organizations have been on a long, winding road to value-based care, but the promise of improved patient outcomes and reduced costs is nearing as value-based care gains traction.

According to a recent Lumeris survey, more than 90 percent of health system executives expect value-based contracts to continue growing in the coming years.

This transition hasn’t happened overnight – it requires stakeholders to reimagine how information is captured, stored and shared. That’s a dynamic fraught with complication, and creativity can be limited by technology investments that have been made along the way.

There are four major components that must be present for a VBC network to thrive:

  • Implementation of a robust data infrastructure.
  • Realignment of downstream reimbursement to include both medical and non-medical providers.
  • Incorporation of social determinants of health (SDoH) resources and partners.
  • Instrumentation of a dashboard view into performance against all contracts along the way, rather than just at year-end.

These components enable risk bearers to become nimble and accomplished at required core competencies, which include:

  • Leveraging a single source of truth for value-based care contract execution and performance information that can be shared by upstream and downstream participants.
  • Enforcing a concerted effort to remove data silos.
  • Accommodating the large variety of evolving payment methodologies in force today and those that will appear as VBC matures (for example, shared risk/ACO-like arrangements, bundled payment programs, full and partial capitation, the Medicare Shared Savings Program with upside and downside risk and more).
  • Executing whole-person care plans that orchestrate the use of traditional “network” medical resources simultaneously with non-medical, community-based resources – all from a single infrastructure that aligns performance against financial responsibilities.
  • Employing a constant “evaluate-adjust-execute” business cycle to manage all VBC contracts against resourcing throughout the year, maximizing financial value.
7. Value Slideshow AdobeStock_79863300.jpeg

The orchestration and coordination described in the above components and competencies must occur across sites of care, in both medical and non-medical resource networks, and can be called value-based administration (VBA).

VBA and its purpose
While both payers and providers would like to efficiently administer value-based arrangements at scale, the existing claims and clinical workflow-based legacy technology investments do not make that a practical possibility. The principal barrier is the inability to manage a complex care network involving several stakeholders in different roles while accommodating the requirements of rapidly evolving, non-claims measured value-based payment models.

The critical function of VBA is to extend those critical legacy systems, installing the flexible hierarchical partner models, digitization-based data capture, and data sharing capabilities that are necessary to execute value-based programs.

In the grand pursuit as an industry for better outcomes and lower overall costs, VBA-enabled networks will facilitate whole-person care by simultaneously orchestrating medical and non-medical care delivery resources and services. When implemented broadly, VBA will operate at scale and be accessible across the spectrum of care settings ranging from site-based to virtual to in the home.

It is important to acknowledge the dilemma faced by many healthcare stakeholders. They must weigh the new crop of requirements against the challenges of meeting them in spite of the limitations of their legacy IT infrastructure and the unintentional data silo inefficiencies created by the data analytics and digital tools built to solve the problem.  As a result, many leaders and organizations may hesitate at the idea of scrapping what they have and starting over. With the goal of creating leverage from the information locked up in those legacy systems, VBA should be incremental and not duplicative to previous technology investments, focused on the information required to data share, execute, pay downstream partners, and analyze performance on VBC commitments.

The application of VBA
Successful execution of VBA coordinates the “many to many” relationships between VBC stakeholders and their counterparts within the various VBC contracts in play. These may include health insurance carriers, risk-bearing entities such as accountable care organizations (ACOs), clinically integrated networks, and carve-out programs from chronic disease management, primary care, care management programming, social services networks, and community-based organizations (CBOs).

An enterprise approach to VBA enables information capture and sharing, necessary business-to-business and business-to-consumer multichannel communications, and accomplishes the required financial arrangements for partners upstream and downstream.

Administrating the upstream capture of funding pools and downstream distribution to VBC network partners is one of the most critical functions of a VBA approach. This results in alignment with a wide range of disbursement models operating within the given network.

To illustrate, consider the following example of the variability within a given plan of care for the same patient:

  • A physical therapy provider should be transferred full payment after documenting receipt of the required post-visit status report for the patient.
  • A Meals on Wheels community provider is paid after receiving confirmation of food delivery for the patient.

Both the medical and non-medical resources need to be able to execute their respective duties within a diverse plan of care while utilizing the same set of referral, status and confirmation information and technology rails.

That's the essence of VBA. Healthcare is changing before our eyes into an empowering experience more proactive in nature and one that increasingly incorporates the whole person, for example, as SDoH and services are provided by community-based organizations. Both payers and providers want to establish care systems that focus on the whole of the person, are outcomes driven, and reduce financial burden for all parties. VBA is required for key stakeholders to manage complex contractual relationships between network partners while enabling their complete participation and maximizing the care delivery value they contribute and the financial reward they receive in return.

Lynn Carroll is the chief operations officer and Rahul Sharma is CEO of HSBlox.

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