Under the fee-for-service model, it makes sense for providers and payers to withhold information. But the shift to value-based care requires the timely integration of clinical and claims information.
A combination of comprehensive data, sophisticated analysis and rigorous modeling are essential to unlocking the potential of value-based care. Yet without a culture of information sharing and the unification of individual datasets, healthcare organizations will be limited in how they can most effectively develop an equitable framework to allocate risks and rewards among participants.
The data necessary to support value-based care is ultimately a function of how it is defined.
In the 13 years since the passage of the Affordable Care Act, healthcare organizations and other stakeholders have recognized that tracking key performance indicators such as readmission rates, average length of stay and patient satisfaction are insufficient to realize the full potential of a patient-centered care experience.
As value-based care models mature, measurements have expanded to include the social determinants of health and other issues that providers and payers must consider if they are to treat patients holistically. This includes the availability of transportation, family assistive services, affordable housing and other factors that provide a foundation for population health.
This progress is encouraging, but the industry still has a long way to go. Clinical and financial metrics are just one lens to assess the success in delivering value-based care, and even medical, demographic and economic data is insufficient. More granular, incisive data on the healthcare industry itself is required to fully assess how much progress the industry is making in delivering value-based care.
Compiling all this data is, admittedly, a very tall order. This data resides in a variety of locations in a wide range of formats. These include electronic health records, claims and billing activities, product and disease registries, patient-generated data and even data gathered from mobile devices and online transactions.
We are in very early days yet. Still, there are some encouraging developments. A number of newly emerging companies are attempting to do for healthcare what Zillow and Trulia have done for real estate: integrate a vast amount of information from siloed sources, analyze it and develop specialized products that serve customers across the healthcare ecosystem.
Such information, for instance, can help healthcare providers better understand the landscape of their local markets, map the patient journey and identify touchpoints that would enable them to improve and amplify efforts to deliver value-based care. Equally important, it would allow them to zero in on the most complex patients — that 15% that generates 60% of the costs.
Other companies are concentrating on helping organizations surface information buried in their existing datasets.
For providers, this might mean mining their electronic health records to identify patients most likely to benefit from interventions and to optimize and automate workflows around care management.
For payers, this might entail combining clinically integrated data with predictive analytics to help providers close a care gap.
Primary care providers have become the leading consumers and innovators in the use of healthcare data because it places them in the position to take a major share of the responsibility for patient health and act as a coordinator of care. Today, some specialties, especially those with an established predictable path for care like oncology and nephrology, have begun to adopt value-based models.
Partnerships are the key to realizing the potential of data for value-based care —and these require communication and trust. Providers have increasingly turned toward management services organizations (MSOs) to facilitate such partnerships, and their success is based on collecting and analyzing critical data for decision making.
Most importantly, it will require close partnerships between provider and payer. Under the fee-for-service model, it makes sense for providers and payers to withhold information. Payers want to lower costs; providers increase revenue. In value-based care, the goal is to benefit patients. That shift requires the timely integration of clinical and claims information so, for instance, providers have a clear understanding if they are within budget or not.
Comprehensive data collection and sharing is not the only prerequisite for the transition to value-based care. Organizational silos must be broken down, regulations may need to be updated or revisited, and incentive systems may need to be realigned.
And even if these issues are resolved, a unified data ecosystem will provide the foundation for the next generation of patient-care technology and tools that will empower the industry to provide the right care to the right people at the right cost.
Anne Chau is a senior vice president at Capital One Healthcare.