Providers, payers must share data to succeed in value-based care

Real-time clinical data and knowledge generated from claims data are critical to success, says Richard Gundling of HFMA.

The transition from fee-for-service to value-based care has the potential to transform healthcare. But to be successful under this new business model, providers and health payers must share claims and clinical data, according to the Healthcare Financial Management Association.

HFMA recently issued recommendations on how to prepare for value-based payment to help healthcare organizations with strategic planning and to encourage them to collaborate with health insurers on risk-based models.

“As part of these innovative payment models, health plans should provide model participants with access to claims data—both raw claims feeds and aggregated management reports,” states HFMA’s guidance.

“Raw claims feeds will allow sophisticated organizations to conduct their own analyses, while aggregated reports will provide smaller physician practices with actionable financial data,” the report states. “While access to longitudinal claims data allows hospitals and physicians to retrospectively identify opportunities to improve care, access to real-time clinical data allows for faster interventions that prevent unnecessary utilization, improve outcomes, and in some instances (particularly with medications) save lives.”

Thomas Foels, MD, executive vice president and chief medical officer at Independent Health, says that the not-for-profit health plan headquartered in Buffalo, N.Y., provides its partner physicians and providers with data and insight on practice patterns and other metrics to help them with the transition to value-based care.

Also See: Insurers also buffeted by the transition to value-based care

“When you’re looking from the physician’s perspective, either a primary care doctor or specialist, a greater percentage of their patient panel is now moving toward some form of alternative payment,” says Foels. “But, what we’re seeing is some initial hesitancy by providers because this is a new system of reimbursement.”

According to Foels, most doctors “do not have a sense of how they’re performing relative to their peers or—for that matter—how physicians within their group are performing.” Nor, do they realize what the total costs of care are, he adds, and that’s why it’s important to supply them with that information.

When it comes to sharing clinical data, HFMA contends that the “sort of interoperability standards that would allow real-time access to clinical data remain elusive for most providers” and that “hospitals and physician groups must push their vendors to provide true data interoperability across electronic health record platforms—without additional financial costs.”

“We’ve got to find ways to integrate the data from the EHRs in the providers’ offices and get that into our data warehouse,” says Ann Pentkowski, Independent Health’s senior vice president for network and performance management. “Things in their EHR systems are not in our claims system.”

Pentkowski says Independent Health is attempting to obtain that clinical data from HEALTHeLINK, a health information exchange serving providers throughout the eight counties of Western New York. “We’re looking at trying to be able to extract some data out of that coming in from EHRs from the providers to get our members’ information,” she adds.

Nonetheless, HFMA’s Health Care 2020 report asserts that the promise of regional health information exchanges has “remained largely unrealized for want of a sustainable business model and development of a unique patient identifier.” As a result, the report argues that “all stakeholders must work with consumer groups to develop a protocol for unique patient identifiers that balances the societal expectation of privacy with the need to provide caregivers with potentially lifesaving comprehensive patient clinical data.”

Richard Gundling, senior vice president for healthcare financial practices at HFMA, makes the case that having good business intelligence and decision support systems in place are critical for the value-based environment. “Organizations are going to need the costing tools and analytics to be able to manage the data,” he says. “Estimating your exposures and predicting outcomes has huge IT implications. We’re seeing analytics rapidly growing in healthcare under value-based reimbursement. You need to understand the data to be able to make decisions.”

According to Gundling, health systems will need to understand both their per-unit price relative to their competitors and the overall cost of care for an episode—and determine what they can do to reduce production costs and overall episode prices.

For its part, Western New York Urology Associates and its affiliate company, Cancer Care of Western New York, have partnered with Independent Health on a series of value-based initiatives. As a result, Western New York Urology and Cancer Care of Western New York’s cost-per-episode rate for prostate cancer treatment is far less than its peers while still surpassing all quality measures, says Foels.

Pentkowski notes that Independent Health has been working with Western New York Urology Associates for several years now and uses a tool that compares the provider on “an episode basis” between physicians and their peers including for metrics like utilization and cost. She adds that the insurer meets quarterly with the provider to review the data to help them meet/exceed national and local benchmarks of quality and efficiency.

“Providers who are not yet in value-based contracts should be looking for health plan partners willing to experiment with new pay models so they can hit the ground running when value-based payments become the norm,” advises HFMA in its report.

Foels observes that physicians are actually approaching Independent Health for assistance in “working through an alternative payment model that creates a win-win strategy” for both the provider and health payer. “It’s not top-down any more, it’s bottom-up,” he concludes. “Providers are approaching us as often as we’re approaching them.”

At the same time, Pentkowski emphasizes that as a health plan it’s important to get provider input and “not just dictate” when developing the value-based programs.

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