After the Covid-19 pandemic, the U.S. continued to gain momentum in its shift from a fee-for-service healthcare model to value-based care (VBC). This is because the revenue of providers operating on a fee-for-service basis has fallen sharply for most of the last year, because selective procedures have been cancelled and many patients have postponed primary care, even for chronic diseases. Quite simply, under the traditional medical payment model, no service equals no payment.
In contrast, providers who signed a risk-based contract received a specific amount, whether it was each member or each patient, regardless of whether the patient received health care services. CFOs don’t need to realize that something is better than nothing. Surgeons do not need to know that a reimbursement model that rewards providers for quality care while controlling costs will bring better results for patients, providers, and payers. This is the promise of VBC and risk-based payment models.
However, for many providers, there is a major obstacle preventing them from adopting VBC and alternative payment models-the lack of timely and actionable data. VBC and risk-based contracts focus on preventive healthcare and health, while “holistic care” adds to the care equation by including the mental and emotional health of the patient or member.
Taking care of the whole person means understanding the connection between physical conditions (such as diabetes and congestive heart failure) and the components of behavioral health. This knowledge enables providers, patients and payers to develop comprehensive and effective care plans.
However, if there are no suitable tools to collect and analyze patient and claim data—including the social determinants of health (SDOH), such as the patient’s socioeconomic status, housing security, and access to food, medicine, and transportation—providers are very Difficult to be proactive.
Taking care of the whole person requires understanding whether plan members or current patients can use fresh fruits and vegetables, taking Uber to regular doctor appointments, participating in smoking cessation programs or social support networks, etc. to help cope with the long-term impact of Covid-19. In fact, during the worst of the pandemic, demand for behavioral health and substance abuse treatment services surged as millions of Americans struggled with depression caused or exacerbated by fear, isolation, and economic anxiety.
Surprisingly, many providers still rely on Excel spreadsheets to track extensive quality and claims data for various care models. These huge data sets quickly become difficult to access in a timely manner. Even in a traditional data warehouse, there is no way to efficiently integrate aggregated data; people must enter and actually hard-code such reports, which can take months to achieve.
In addition, different health systems have different levels of complexity. They may have data, but they don’t really understand what the data tells them or the best action to take based on the information. Or decision-making is hindered because the available data is not up to date, and the data sources are isolated and difficult to summarize.
The only way to manage hundreds of measures for different types of healthcare contracts is to use advanced analytics. Unless you can view data through different prisms (such as chronic disease, SDOH, and behavioral health), you cannot act on a group of patients. To do this, you need analysis that turns data into useful and actionable information.
Analysis enables providers to significantly improve the quality of care they provide because they are equipped with actionable insights, such as when the patient was last tested for a specific disease or whether the patient was complying with prescription medications. Through a preventive holistic approach, patient care can be enhanced, preventable high-cost care events such as emergency room visits and hospitalizations can be minimized, and medical care costs can be reduced.
Therefore, it is not surprising that analytics can help providers and payers collaborate more effectively to reduce healthcare costs. For the payer, the analysis eliminates the long lag in claims data. Although clinical data is usually up-to-date, providing information to any provider who provides care to members or patients can be a daunting challenge.
Ideally, providers need clinical and claims data. The claims data will tell you where the patient received healthcare services so that the health system knows that the patient has also seen a non-affiliated specialist-this is valuable for clinicians seeking to treat the whole person.
This goes back to the fundamental benefits of VBC: by taking a proactive and comprehensive approach to member and patient care, better results and lower healthcare costs This also provides information for the health of the populationImagine having all patient and claim data in the Health Information Exchange (HIE), and multiple health systems providing the data. It will allow viewing of patients and populations throughout the metropolitan community. It all starts with data.
But data is not information. Analysis is the transformation of data into information about patients and member groups. Applying analysis to integrated data including SDOH enables providers and payers to improve the quality of care and effectively manage financial risks through a value-based model.
For healthcare organizations eager to adopt advanced analytics as a VBC approach, here are some suggestions to consider:
- First, using analytics to manage risk is not a consulting project. It may seem like a good idea to hire “experts” to analyze your possible underperformance from a risk perspective, but once these consultants leave, you will no longer get new data. Providers and payers need the ability to conduct self-monitoring through analysis so that they can have continuous insights into clinical and financial performance.
- Second, the advanced healthcare analysis platform cannot be regarded as an IT project. This is a business plan designed to solve complex business challenges. Therefore, you need input and support from stakeholders across the business functions of the organization. You also need a user-friendly interface that enables clinicians and nursing managers to easily access and manipulate data.
- Finally, use new technologies such as the cloud to put powerful solutions in the hands of clinicians and nursing managers so that they can proactively manage their members and patient groups. Advanced analytics as a service is a highly scalable and reliable delivery model.
Value-based healthcare requires technology to measure, predict, and improve services based on medical and behavioral data (including SDOH). Such tools enable suppliers to provide better results that demonstrate value. By adopting flexible healthcare analytics solutions to measure and analyze different data sources and promote a holistic approach to healthcare delivery, providers can better promote the success of value-based healthcare.
