Lynn Carroll 

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There’s good news and bad news when it comes to the evolution of value-based care in the U.S. Let’s start with the good news. A 2021 study from the Health Care Payment Learning and Action Network (HCPLAN) shows a continued move from fee-for-service models to value-based care (VBC). According to the study, 39.3% of healthcare dollars spent are tied to traditional fee-for-service payments, 19.8% are tied to pay-for-performance, and 40.9% are part of some type of value-based contract (e.g., shared savings, shared risk, bundled payment, population-based payments, etc.).

Now for the bad news. While the trend toward VBC is promising, research also shows it can take a long time for healthcare payers to effectively implement these new payment models. According to a 2018 study, only 21% of payers say they can roll out a new episode of care in three to six months, more than 33% say they need a year, 21% need 18 months, and 13% require two years or more.

This inconsistent implementation pace can impact the overall adoption and success of VBC programs nationwide. Addressing this issue requires resolving several universal challenges that currently hinder the ability for many healthcare payers to quickly implement new VBC payment models.

A common implementation barrier is legacy claims and workflow technology investments that don’t support the management of the complex multi-stakeholder care networks involved in VBC or the episodic requirements of payment models that aren’t claim centric. Another barrier is the timeliness of data reporting and the inability to understand contract performance more prospectively as opposed to after-the-fact.

While technology and data exchange challenges impact both payers and providers, payers will likely need to take the lead in this area to make progress. This is primarily because payers are often responsible for not only educating providers on VBC models, but also bridging the gap between fee-for-service and VBC. Serving as a catalyst for this change and positioning the industry for VBC nimbleness requires payers to rethink the existing infrastructure paradigm. 

Successful administration of value-based programs requires an infrastructure that enables the many-to-many relationships between VBC stakeholders and their counterparts. This includes health insurance carriers as well as risk-bearing entities such as accountable care urganizations (ACOs), clinically integrated networks, carve-out programs for chronic disease management, primary care, care management programming, social service networks, and community-based organizations (CBOs). The administration of funding pools, including downstream distribution of funds and data exchange to participating partners, is one of the most critical functions of successful value-based execution.

For both payers and providers, traditional approaches and legacy systems do not support the hierarchical relationship structures necessary for onboarding stakeholders in value-based contracts. Likewise, orchestration of cascading payment models, where payer/provider collaborations incorporate risk-bearing entities and downstream participating providers, are not easily scaled, reducing the ability to accelerate adoption of varied alternative payment models. This hierarchical approach to partner onboarding, scaling of contract operationalization, and permissioned data sharing is a necessity for alignment of medical, social, behavioral, and environmental components of successful value-based program administration and high-performance networks that confidently deliver on whole-health patient outcomes.

An infrastructure for VBC not only requires hierarchy support, but also the ready exchange of a more comprehensive set of health data. Traditional electronic health record (EHR) systems were built to solve the challenges of transactional data related to claims submission, billing, and processing of adjudication, clinical data, and pharmacy data. VBC requires more insight into patient health and outcomes. It requires the creation of a longitudinal health record (LHR) that not only manages and shares traditional structured EHR data (e.g., data that fits neatly into fixed fields), but also enables the proper digitization and exchange of clinically rich data that resides in unstructured form as charts, notes, images, audio and video files, as well as freeform text of character large objects (CLOBs).

Advanced technologies such as artificial intelligence (AI) and machine learning (ML) make this possible, providing a unified view of the patient that allows for a move from transactional processing to an outcome-driven, value-based model focused on patient-centered care. However, a data infrastructure truly enabled for VBC also needs to be based on ontology mapping rather than traditional relational or nosql databases.

An ontology encompasses a representation, formal naming, and definition of the categories, properties, and relations between the concepts, data, and entities that substantiate one, many, or all domains of discourse. For example, changing a property from single-valued to multi-valued in a relational database requires the entire column for that property to be deleted and an entirely new table to be created that holds all the new property values. By contrast, all data modeling statements in ontological languages are incremental. Enhancing or modifying a data model after the fact can be accomplished simply by modifying the concept, making the synthetization of patient health data across entities much easier.

When it comes to ontologies for the patient data sets, there are 18 different sets that these would fall into:


Clinical data (e.g., notes, charts, X-Ray, MRI, radiographs etc.)

Financial Data (from banks for loans, AR reports, patient responsibility from claims)

Social Determinants of Health (SDOH) Data

External summary data sources for analysis (WHO, CDC, Johns Hopkins etc.)

All this data needs to have an underlying Enterprise Master Patient Index (EMPI) to tie the data sets to the right patient together and tie it to the unique identity enumeration done for that patient.

Microservices aid permission-based sharing

The underlying data infrastructure outlined in the previous sections can then be exposed via a secure and scalable Data as a Service (DaaS) layer on which different applications and integrations are built, creating a network of networks for permissioned-based data sharing that enables a move to VBC. This DaaS layer is important because it allows an adaptable VBC infrastructure to be realized without a rip-and-replace strategy. Data layers can instead be integrated and extended seamlessly, allowing stakeholders to use existing applications served up via microservices and extend or create microservices and business applications for their own needs.

The trend toward VBC is driven by a desire to improve patient outcomes while lowering healthcare costs. Payers play a central role in establishing the hierarchical infrastructure necessary to accelerate and scale the implementation of new VBC models throughout the continuum of care.

APM Measurement: Progress of Alternate Payment Models – HCPLAN – 2020-2021

Payers moving to value-based care faster than expected – Healthcare Dive – Len Masterson – June 18, 2018

is CEO of HSBlox, a healthcare technology in suburban Atlanta that supports value-based technology. 

is the chief operations officer of the company. 

Articles

While the trend toward value-based care is promising, research shows it can take a long time for healthcare payers to effectively implement the model. Value-based programs require an infrastructure that enables the many-to-many relationships between value-based care stakeholders and their counterparts.

  Transforming Payer Infrastructure to Accelerate Value-based Care

The transition from treating patients at a provider’s site to delivering care in the home and community requires two things: an ability to incorporate social determinants of health (SDOH) into the care coordination process and the inclusion of value-based care (VBC) and community-based organizations (CBOs) as compensated care delivery partners in VBC networks.

For health plans, risk-bearing providers and risk bearing entities (i.e., altogether referred to as “payers”) alike, we recommended implementing a Partner Onboarding Model that enables scale today and flexibility in the future. In this article, we explore the current environment and how payers and providers can take the critical first step to add CBOs to their VBC contracts and ensure they are compensated.

The concept of assembling, managing, contracting and paying for medical provider relationships has evolved over many years, with innovation born of necessity. Payers have had many years to figure out how to:

Organize providers in a way that saves employers money

Know which providers are willing to share risk (and which aren’t)

But with the current focus on VBC creating payer advantages by adding CBOs to the network of providers used to execute care plans, they won’t have the luxury of figuring it all out over decades. Contracting, secure information sharing, outcome measurement, and payment to partners across all up/down-stream partners become table stakes for payers on Day 1.Also, as it is likely that resource outlays have already been made for infrastructure to secure a portion of these table stakes, thus, whichever path forward is chosen, it must at least leverage existing tech investments.

Supporting CBOs within a VBC contract introduces an unprecedented layer of complexity for payers. On the broadest level, payers familiar with today’s “one to one” relationships with a specific provider or set of providers must also now be able to maintain “many to many” relationships that could include a mix of financial and data-sharing models in each. Without automation to manage execution of these increasingly complex, multiparty contracts, payers will find themselves quickly overwhelmed, being forced to hire additional employees to manually execute invoice-payment, track status and audit for accuracy.

There are differing business processes that may be required simultaneously across a given service provider network, ultimately governing how information is shared securely. As such, a payer preparing to transact value-based care will likely have several questions come to mind:

With so many partners, are we sure we have the patient’s consent?

Is there a CBO in our network that doesn’t understand HIPAA?

If a provider doesn’t have/can’t provide electronic visit verification (EVV) for a home visit, how does that impact our mutual relationship?

Can all my providers produce an electronic invoice for their services, or will I have to help them provide it?

Although the above is not an exhaustive list and others will most certainly surface, these business processes must also manage details of multiple financial models and outcomes measurements across the relationships – i.e., is a particular partner reimbursed, subsidized, incentivized or fully/partially capitated – or is it some combination thereof?

The ability (or inability) of the down-stream partner to support the various models becomes a factor in the relationships you can form and how quickly.At least initially, a payer’s partners in a VBC contract – particularly CBOs with smaller budgets – may lack the technology to efficiently participate. To overcome this obstacle, payers may need to consider “providing” their downstream partners with the ability to contract, measure, pay and get paid.

Implement for complexity, plan for flexibility

Payers need a partner onboarding model that handles complexity with the supporting technologies to create a VBC network that integrates, supports, leverages and compensates CBOs – thus, delivering immediate scale and providing an element of future proofing. It is 

 critical first step in developing a sustainable VBC network.

A payer’s partner onboarding model and related technologies must drive all mission-critical business processes, including:

The onboarding model and supporting technologies also must be able to meet the needs of each key stakeholder – payers, risk bearers and delivery partners – and accommodate “many to many” relationship models. This means nimbly managing upstream payment receipt, measuring critical metrics, and executing partner payments in an environment that protects downstream proprietary relationships – 

 used to deliver on the mission-critical business processes listed above and doing so with the security and audibility required in today’s heavily regulated healthcare information exchange environment.

Once partners are onboarded into a structure that facilitates their roles and financial arrangements, ebbing and flowing based upon their involvement, payers will have created a “network of networks,” providing a competitive advantage while simultaneously allowing them to better serve patients and their communities.

Lynn Carroll is the chief operations officer, and John Schwartz, the chief revenue officer, of 

, which enables SDOH risk-stratification, care coordination and permissioned data sharing through its digital health platform.

The transition from treating patients at a provider’s site to delivering care in the home and community requires two things: an ability to incorporate social determinants of health into the care coordination process and the inclusion of value-based care and community-based organizations as compensated care delivery partners in VBC networks.

Exploring the Critical First Step in Adding and Paying CBOs in Value-based Contracts

Value-based care is now firmly entrenched in our healthcare system. Payers credit value-based care with lowering costs, improved outcomes, enhanced payer/provider relationships, and improved patient engagement.

With the growth of value-based care models, a trend gaining traction is the transition from treatment at a provider’s site to a patient’s home. This shift to home and community-based care, accelerated by the COVID-19 pandemic, shows no signs of abating.

Value-based care is well-suited to handle this change. This model by its nature is focused on wellness; members don’t always need facility-based care. Moreover, value-based care factors in both medical and non-medical aspects of an individual. The question then is how best to keep members healthy at home.

The Importance of Incorporating Social Determinants of Health

One integral way for payers to leverage this shift is to ensure that they capture the member’s social and behavioral information as well as medical information for use in affecting the plan of care. A fundamental yet still nascent component of value-based care is seeing members more holistically and integrating social determinants of health (SDOH) data with clinical data. SDOH data – such as access to healthcare and safe housing, and economic stability – affects a wide range of health risks and outcomes.

There is a growing consensus that SDOH need to be taken into account in order to succeed in providing value-based care. Payers that align medical and nonmedical data, and address SDOH for those members that need such assistance have seen lower costs, improved health equity, and more effective care coordination.

Bringing Community-Based Organizations into the Fold

To fully leverage SDOH information and provide more complete services throughout the care continuum in support of value-based care, payers should include community-based organizations (CBOs) in their value-based care network contracting strategies. Doing so creates a broadened, higher performing set of resources to keep people healthy and at home.

Taking the leap and making CBOs a compensated part of the care continuum provide several advantages:

First, broadening the perspective on the member: CBOs and social services agencies (SSAs) help determine at a “street level” the personalized services payers should provide as well as assist in identifying risk factors to suggest targeted care.

Second, a more complete picture of care plan success: increased closed-loop referrals, whereby the clinician who refers a patient to a CBO receives notification once the referral is acted upon, or perhaps more importantly, knowing for certain when it is not.

Third, a cost advantage, and financially stronger community assets that are attune to the shifting needs of the community: CBO services are typically cheaper than medical services, an added plus and benefit greatly from a non-philanthropic revenue stream.

If we are being honest with ourselves, aligning traditional medical networks to incorporate CBOs is not without its challenges. For instance, not all CBOs are subject to the Health Insurance Portability and Accountability Act (HIPAA) and other privacy laws, which, if not appropriately architected, can raise privacy and security concerns.

A further barrier is revealed as each value-based care network partner approaches adding CBO information into the technology used to run their business (e.g., hospital information systems and practice management systems) as about 80% of the data required to do so is unstructured. On top of both these hurdles is the enormous sunk cost in the existing IT investments made by the stakeholders – a solution that requires abandonment of those investments is economically unfeasible.

That all said, it can be done, and done today. Payers that are incorporating SDOH into their value-based care programs typically layer SDOH technology platforms onto the medical network’s existing infrastructure to add these capabilities. There is no need to “rip and replace.” Unstructured CBO information can be digitized and included in a medical provider’s electronic health record (EHR) to create longitudinal health records (LHRs) covering the care continuum.

Compensating non-medical partners such as CBOs differs somewhat from payment to a medical provider. Payers need a mechanism for a CBO to submit an invoice, which often will not be digital, and confirmation of verification of the service, such as electronic visit verification (EVV), to trigger payment.

For instance, a social worker contracted with a value-based care network would look in on members regarding their needs and inform them of services available. The payer would confirm the visit by obtaining the clinical, social, and/or behavioral service completion documentation (e.g., via a member form, or via an agreed upon detailed invoice from the CSO digitized to extract the required information to confirm the visit), accept the invoice from the CSO, and then initiate payment.

Best Practices to Integrate, Compensate CBOs and SDOH Data

As the time is now to incorporate CBOs and SDOH into a payer’s value-based care program, payers should embark upon a thoughtful and proactive planning process taking these steps:

Integrate CBOs and SDOH into your current business model. Fold it into the network’s current workflows and align with the network’s medical services. Fit it into what you’re already doing. That is easier and less expensive than operating medical and non-medical data separately.

Layer SDOH technology platforms into your existing infrastructure. Use complementary solutions to plug gaps, support EVV and invoicing, and create fully digital and actionable medical records.

Put procedures in place to emphasize security, since there will be data sharing outside the purview of HIPAA. This entails not only strong language in the CBO contract to address privacy and security safeguards, but also capturing patient consent and incorporating role-based, permissioned data sharing.

Enhance interoperability. Ensure that different data systems can communicate with each other to securely exchange SDOH information among stakeholders – this means prioritizing the ability to digitize unstructured data.

Be flexible about technology and payment methods. Not all CBOs are tech-savvy. For example, some of them cannot accept automated clearing house (ACH) payments.

The shift to home- and community-based care requires alignment between traditional medical service delivery and non-medical home and community services. Payers should include CBOs in their value-based care networks to prospectively address risk-management, capture SDOH data and enhance the network’s performance. Since CBOs are not traditionally part of payer networks, payers need to deploy mechanisms to support the logistics of CBO service delivery, invoicing, and compensation. Value-based care is poised to grow significantly; payers that can master CBO payments now will be the best positioned for success.

Lynn Carroll is the chief operations officer, and John Schwartz, the chief revenue officer, of HSBlox, which enables SDOH risk-stratification, care coordination and permissioned data sharing through its digital health platform.

Lynn Carroll

Articles

Transforming Payer Infrastructure to Accelerate Value-based Care

Exploring the Critical First Step in Adding and Paying CBOs in Value-based Contracts

How to Add, Pay Community-Based Organizations in Value-based Care Contracts