Informational parity is the key to better value-based care agreements

The shift from fee-for-service to value has made slow progress for the last two decades, and over time value-based care (VBC) has gone from the buzzword of the day to a term that prompts eye rolls in some circles. Frustrations abound as payers and providers both actively work to put patients at the center of care, to reduce costs and elevate outcomes in the spirit of VBC, and yet fail to fully realize their vision. For VBC to reach its potential, new mechanisms for collaboration are desperately needed, including a fundamental change in the way the key stakeholders in the system interact. The bottom line is that there needs to be more real-time, shared data—what we call “collaborative care data”—to facilitate understanding of what's happening to patients as they move through the healthcare system.

Barriers to accelerating VBC

One of the great ironies in healthcare is that most payers already have a large book of business under value-based agreements; these contracts are collectively worth billions of dollars. But there is less true risk sharing in these agreements than one would think. Most often, payers and providers are taking a retrospective approach to the assessment of health outcomes, where both parties are likely sitting down to reconcile what did—or did not—happen many months after the fact. Working in this manner can sometimes pit the two parties against each other, as care decisions have already been made and costs incurred. Conversations may center on who is to blame, what could have been done better, why more proactive treatment wasn’t given to polychronic patients, and why utilization spiked. The upshot is that, frequently, the shared goal of improving patient care takes a back seat.

In addition to a retrospective approach to outcomes analysis, there’s also a fundamental disconnect payers and providers aren’t looking at the same measures or data sources. Payers have huge stores of utilization data, but they lack visibility into the clinical data and workflows that drive health system care decisions. Health systems have a trove of patient data, but they don’t have the ability to connect and operationalize data in the way that insurers do. Most also tend to have data from people in just a particular city or region, while payers typically cover multiple cities and states and may even have a national view of population health.

And neither party likely has access to complete consumer data, whether that’s the frequency with which a member or patient refills a prescription, sleep and exercise data from a wearable, or importantly, consumer spend on nutrition or healthcare items. Put simply, no single stakeholder in the system has a true 360-degree view of the patient population. 

Collaborative care data: The key to bringing payers and providers together

What every stakeholder in the system needs but currently still lacks is an aligned focus on “collaborative care data.” That is, real-time data that span patient journeys across the entire care continuum and into their daily lives. Payers and providers alike need data from patient activity as it occurs. They further need to be empowered to react to care gaps and episodes of care that aren’t occurring in the right setting or at the right time, which can cause tremendous variation in the standard of care. Frequent examples include missed appointments, transitionary care challenges, limited access to healthy foods, lack of transportation, social engagement barriers, issues with medication adherence, and unnecessary trips to the ED.

In addition to identifying and addressing these issues, both parties must have a view of the whole patient—including the social determinants of health—to address root causes through preventive care, provide better management of chronic conditions, and to eliminate barriers to care.  

We know that payers and providers want the same thing—better health, delivered with a better patient experience, at an affordable cost. The typical national payer, for instance, uses up to 15 vendors to try to address the needs of its members, making it abundantly clear that they are every bit as dedicated to addressing the whole patient as their provider counterparts.

Imagine a set of tools that enabled payers and providers to look at all of these issues in real time together, enabling them to work collaboratively to make instantaneous course corrections instead of looking back at the end of the year with recrimination. Better yet, imagine that at the outset both parties could identify and agree on a shared set of measures and process metrics needed to reduce redundancy of care, to increase collaboration of care, and to close gaps along the continuum. Imagine a system where doctors and health insurers shared a sense of trust and common purpose. Instead of doctors worrying about reimbursement and payers pushing for lower utilization of services, the two parties would be empowered to center their conversations around getting the right care to the right people in the right setting at the right time.

A tangible solution to accelerate the shift to value

So, what’s needed to make this vision a reality?

The barriers to advancing value in healthcare—which is a larger issue than just contracting—starts with tools that bring disparate data sources together in a way that’s transparent to all. Ideally, payers and providers—as well as their patients—would have access to the right mix of holistic data about the populations they serve. But that’s just the beginning.

Those stores of data in aggregate would yield incredible insights, allowing providers to do so much more than solve singular problems such as ED overutilization. They would help them identify and implement personalized care plans based on individual member’s goals, routines, work situations, personal passions, social circumstances and even time constraints. They would make preventive care the standard of care and achieve the elevated patient experience that’s at the center of value-based care. And this would occur not just at the individual member level, but at the population level, driving clinical consistency at scale and establishing standards of practice for high-risk groups (e.g., diabetics, cardiac patients, and the elderly).

Brought to life, such a system would have countless benefits to payers, providers, and, most importantly, patients, as well as delivering on the ambitious but feasible goals of value-based care.

Topics: featured, healthcare consulting

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