Payers need more data to optimize patient outcomes under VBC

Claims data gives health plans only a partial view of a patient’s health, and three data sources are critical to better enable connected care.

This article is part of the July 2023 COVERstory.

One of the most important goals of value-based care is to better inform prospective clinical care across all care settings and for the entire care team.

By tapping into the insights derived from value-based care data, healthcare stakeholders maximize every single patient interaction for the highest quality outcomes, regardless of the care venue. As a result, patient care shifts from treating diseases to prescribing preventative interventions that encourage wellness and reduce costly inpatient admissions.

This is the promise of value-based care. However, two immediate challenges remain across the healthcare ecosystem.

  • • Both providers and payers still lack a comprehensive view of the entire patient journey. Outside patient information, including retail pharmacy data, remains siloed and unavailable for clinical decision-making or member management. Value-based care capabilities must be bolstered across the continuum of care.


  • • Most healthcare reimbursements remain focused on billable interventions instead of preventative wellness. Insurance companies reimburse providers for costly medications and procedures, but not preventative interventions. For example, reimbursement is available for insulin, but not for pre-emptive dietary consulting for healthy eating habits.

In his recent book, Outlive: The Science & Art of Longevity, Peter Attia, MD, emphasizes the need to prevent human suffering related to the four horsemen – cancer, heart disease, metabolic dysfunction and neurodegenerative diseases. Many health plans and providers are making great strides in preventing, or at least postponing, negative clinical outcomes related to these four chronic diseases through targeted population health initiatives, wellness programs and other public health partnerships.

But not every healthcare stakeholder is on the same journey toward value-based care. The path varies, and some have not yet begun. But there are several examples of progress that reiterate the need for a 360-degree view of the patient across all stakeholders to successfully achieve the CMS 2030 value-based care goals.

Valuable progress to note

Some of the most valuable examples of progress are demonstrated by accountable care organizations (ACOs). Although accepting downside risk and meeting model requirements isn’t easy, many ACOs successfully achieve their bonus goals.

Driven by stringent quality measures reporting and annual incentive payments, ACOs are valuable test cases for participation in shared savings and other value-based initiatives.

For example, CMS reports more than 700,000 providers, 456 ACOs and 13.2 million assigned beneficiaries will be part of its Shared Savings Program in 2023. CMS’ Shared Savings Program Fast Facts also state the program achieved $2 billion in earned shared savings in 2021, and ACOs saved Medicare $3.62 billion in gross savings in 2021, according to the National Association for Accountable Care Organizations (NAACOS). Something is being done right in these organizations.

Payer-provider collaborations also hold promise for value-based success, as health systems build clinically integrated networks and enter accountable care contracts with national health plans such as Anthem, Humana and Centene.

Payers are also aggressively using technology to go beyond the data and improve care for individuals and populations to ensure quality and reduce costs. But like provider organizations, payers lack comprehensive patient data sets to better coordinate care management — a vital component for value-based success.

Seeking a comprehensive view

No one is immune from gaps in care and unnecessary costs that result from a fragmented patient journey. Despite significant advancements in clinical data sharing and health information exchange, many providers and payers still lack easy access to a complete picture of the patient at the point of care, or beyond.

Better technology integration is necessary for clinicians to know everything that is happening with the patient behind the scenes and maximize every patient transaction. For example, treating clinicians should be aware of pharmacy activity, visits to ambulatory clinics, attendance at wellness events and more.

In addition, all the various member outreach efforts conducted by payers should be visible to the clinician. And because patients don’t seek to interact with the healthcare system unless necessary, it is incumbent on providers to make visits as productive as possible.

Access to a broader set of patient data helps achieve this goal. Just as auto mechanics use a five-point checklist to assess a vehicle while it’s at the dealership, clinicians need access to all patient data to see what’s happening with their patients across the ecosystem. Equipped with this knowledge, providers can maximize patient interactions, make the entire visit more meaningful and improve performance under value-based programs.

Payers face another different data challenge. They seek to proactively identify and follow up with at-risk patients. However, the patient data they receive is nearly always from external sources, retrospective and incomplete.

Three data dependencies for payers

Coordinating care management becomes much easier for payers when they have access to a 360-degree view of each member. With broader insights into patient status, payers can be more effective in achieving their value-based goals. Three specific data gaps must be filled for payers today. 

Pharmacy data. Access to comprehensive medication reviews and medication adherence data is needed here. Armed with pharmacy data, payers can provide the member outreach and consulting needed to avoid duplication and multiple medication interactions.

Ambulatory clinic data. Continual monitoring of chronic conditions (especially the four horsemen) is a strategic component of value-based care. In fact, many payers focus their population health and member engagement efforts solely on patients at risk or diagnosed with these diseases. Because routine screening tests and regular checkups for these patients occur in a variety of ambulatory settings, the associated data is often delayed or never exchanged with payers at all.

Hospital data. While hospital data may appear the easiest to obtain, payers still have difficulty with timely and complete access. This leaves payers with significant care coordination gaps to resolve retrospectively through claims data or manual intervention to request medical records from the provider.

Connected care platforms are being rapidly introduced to aggregate data across these silos for payers and thereby create the 360-degree view of the patient story that payers and stakeholders need to succeed under value-based care.

What’s ahead

Connected care platforms evolve the scope of data collection, aggregation and analysis to include every healthcare stakeholder, even pharmacies. A wider range of digital connections enables more coordinated and patient-centered care, better supports value-based care, and ensures efficiency across every patient encounter.

As the role of connected care and inclusion of pharmacies in value-based care increases, there is significant room for radical paradigm shifts in how healthcare reimbursement is doled out.

The healthcare industry has been steeped in fee-for-service since its inception. Shifting to value-based care is akin to moving from the “carriage era” to automobiles and aviation. It will take time, but it will be worth it.

Mayur Yermaneni has more than 20 years of experience in healthcare across various market segments. He spent the last decade developing solutions and helping companies grow in population health, healthcare analytics, and medical management services.

Return to the July 2023 COVERstory.

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