When Payers Become Providers: The Importance of Actionable Data in Value-Based Care

Access to medical histories and other patient information is key for payviders to succeed in the transition away from fee-for-service payment models

When payers and providers come together, it is a convergence of goals that benefits everyone. Patients get more proactive care, and don’t end up in the hospital for something that was avoidable. Payers are able to lower their costs because providing preventative care means they don’t have to cover unnecessarily reactive care.

A win-win situation like this one is meaningful, particularly in a country where high cost and low value are all too common in the healthcare system. The United States ranks last on healthcare quality, despite spending more of its gross domestic product on healthcare than other high-income countries year after year, according to the annual Mirror, Mirror study from the Commonwealth Fund. A Journal of the American Medical Association (JAMA) abstract says that one-quarter of every healthcare dollar spent in the United States is wasted — between $760 billion to $935 billion.

And while there are plenty of theories about the cause of this extremely expensive problem and many ideas about how to fix it, the one that’s gained the most traction is a move from fee-for-service to a value-based care model — a model that’s been embraced by payers moving into the provider space.

“Value-based care recognizes physicians’ dedication to their patients’ health by reimbursing the provider when their high-quality service leads to better health outcomes,” Bruce Broussard, President and CEO of Humana, said in an op-ed about administrative waste and potential solutions. “It is not about the amount of services they provide or the number of patients they see; it is about using an integrated approach to improve health outcomes.”

A study published in JAMA Network Open authored by physicians from Tufts University School of Medicine and Harvard Medical School found that value-based care can drive down acute care episodes among Medicare Advantage members. Compared to those treated in fee-for-service arrangements, patients treated by doctors in advanced value-based care models had 5.6 percent fewer hospitalizations and 13.4 percent fewer emergency room visits.

The Rise of the Payvider

Payers are being increasingly drawn to the provider space in part because of the aging population and ballooning Medicare Advantage market, as well as the continued shift towards value-based care by the Centers for Medicare & Medicaid Services (CMS). With the goals of patients and providers aligned — to increase preventative care and ward off catastrophic events of the future that require acute care — payers with provider arms can work to deliver cost-efficient, quality care while reducing financial risk and increasing profitability.

While the value-based care model is gaining significant traction throughout the healthcare industry, it does come with additional financial risks for payviders — making actionable data and data-driven insights critical to the model's success. Representing a big shift in focus from the quantity of care to the quality of outcomes, value-based care depends on smart, effective use of electronic medical records.

According to the International Data Corporation (IDC), 70 percent of attempts by healthcare organizations to scale value-based health models will fail by 2023 unless they invest in data-driven governance, operations, and organizational infrastructure. Without detailed information about each patient for optimal treatment plans, caregivers will not be able to fulfill the goals of value-based care. The provider arms of payer organizations need clinical and other data that is accessible and actionable.

Value-Based Care Depends on Interoperability

Without better data governance practices and increased interoperability, value-based care cannot be successfully implemented, a theme that was discussed at the Health Information Management Systems Society (HIMSS) Global Conference earlier this year. 

Shayan Vyas, M.D., Vice President and Medical Director of Hospitals and Health Systems at Teladoc Health, told Fierce Healthcare that “whole-person care” is critical. “When I see a patient, I’m trying to put this puzzle together. The more jigsaw pieces I can put together, the closer I can get to a diagnosis,” he said.

CMS’s strong stance on value-based care has been accompanied by the ongoing work to increase interoperability nationwide, with a legislative push from the 21st Century Cures Act and the resulting Trusted Exchange Framework and Common Agreement (TEFCA).

Payers entering the provider space will benefit from these developments but in some cases lack the technology needed to access and manage the flow of data. Many organizations are hampered by legacy systems and infrastructure that keeps data in silos, and replacing them with one-off solutions is a time and resource-intensive process. Modern data management strategies must be used to handle the growing complexities of data.

The aggregation of healthcare data, which includes but is not limited to medical histories, clinical outcomes, vitals, imaging, lab results, medical device data, and social determinants of health (SDOH), is crucial for payers providing care. Aggregating, streamlining, and normalizing health data from a disparate network of an ever-increasing number of data sets coming in from structured and unstructured sources. A data processing engine that converts raw data into an organized format is needed, as well as an interoperability mechanism to make the data not just readable but actionable.

For value-based care to work, payviders must move to a consolidated data platform that is accessible to all stakeholders and gives providers a 360-degree view of patients for better care and improved clinical outcomes — as well as cost savings.

Fragmented data that exists in different systems and formats is among the biggest obstacles to the transition from fee-for-service to value-based care.

Health Gorilla: Your Single Source of Truth

Health Gorilla is improving outcomes with organized, actionable health data and is the healthcare community’s single connection to a national network of aggregated data. Our interoperability solutions provide the building blocks that provider teams and payers need to improve clinical and operational efficiencies without complex data-sharing agreements or months of integration work.

Health Gorilla’s Health Interoperability Platform (HIP) was built using Fast Healthcare Interoperability Resources (FHIR) standards, and has a data processing engine that aggregates, de-duplicates, and normalizes fragmented records into a standard format. It also has a Master Patient Index (MPI) and Record Locator Services (RLS) that work together to make discovering a patient and their health data more efficient. The result is a longitudinal, high-quality, and actionable record for each patient.

Health Gorilla built our HIP to align with the goals of TEFCA and plan to be one of the inaugural Qualified Health Information Networks (QHINs), helping to establish a nationwide floor of interoperability. To learn more about this pursuit, visit our Path to QHIN page.

Integrations done piecemeal can take up to six months of engineering time, but with Health Gorilla you can go-live in just a few weeks. We tailor our implementation to your organization's unique workflows and provide access to the Health Gorilla development sandbox. Our team of experts is available to answer any questions that come up through the testing and validation period. If you have any additional questions or would like a demo of Health Gorilla’s unparalleled interoperability solutions, please contact us.

Free White Paper for Payviders

The United States ranks last on healthcare quality and first in spending compared to other high-income countries. This crisis of high cost and low value is driving new mandates from the government, innovations in healthcare technology, and market shifts — one of which is a gravitational pull between payers and providers to form “payviders.” 

To learn how the exchange of actionable data gives payers moving into the care delivery space the means to increase quality metrics, membership, and reimbursement, download our free white paper Interoperability and Payers — A Recipe for Impactful Preventative Care.

In this white paper, you’ll learn how a truly interoperable solution can help you find and fill care gaps, improve outcomes, increase operational efficiency, and refine risk modeling.

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