Although reports of the continuing impact of Covid-19 continue to flood the country’s headlines, another rising trend in the healthcare sector has emerged in mainstream discussions: value-based healthcare. For many years, value-based care, a model that rewards better patient health outcomes, has been discussed as a lofty dream or an ideal model of care that curves the cost curve. Today, this “distant dream” is more a reality than ever before-mainly due to the recently implemented interoperability rules.
Only last year, new interoperability requirements accelerated the adoption of value-based care by improving data sharing across the healthcare continuum. For example, the Center for Medicaid and Medical Insurance (CMS) recently began implementing the Interoperability and Patient Access Final Rule (CMS-9115-F), which requires payers and providers to grant patients access to their health information. In addition, under the new interoperability rules of the Council for Affordable Quality Healthcare (CAQH), CORE-certified health plans will need to provide providers with updated value-based care patient rosters on a monthly basis. The goals of these rulings are to smooth the workflow, reduce unnecessary churn, and prevent data stagnation. By accessing this timely information, the provider’s encounter or claim information can be more accurately passed through the health plan system and provide real-time information about the performance of value-based care contracts.
The key to value-based care? Interoperability.
Although many healthcare leaders understand the intent behind these new regulations, many people may have heard of these regulations and immediately worry about the resources required to comply with them. The good news is that there is a roadmap to make the implementation more seamless.In fact, CAQH has designed, developed and approved new X12 EDI operations and infrastructure rules will add this important information to the regular eligibility transactions passed between payers and providers every day. These new X12 EDI operations and infrastructure rules will provide the necessary information needed by the point of care to ensure that value-based care attribution is identified and quality measures are effectively addressed.
Together with CAQH, other industry organizations are working to help organizations comply with these regulations by promoting interoperability standards that support the adoption of value-based care models. Working groups throughout the healthcare industry focus on payment models, with the goal of improving the efficiency of health data exchange through education and publicity between payers and providers. Initiatives by other groups and the private sector are also helping to define industry best practices to implement consumer-oriented data exchange.
Value-based care in action
With the adjudication in place and innovative groups helping payers and providers organize and implement, value-based care is becoming a reality and improving patient outcomes. For example, a leading organization proactively designed a new plan early on to transform reimbursement from a fee-for-service to value-based care. The program rewards long-term service and support (LTSS) facilities and nursing facilities to provide high-quality and efficient treatment of respiratory diseases. The organization implemented a quality framework based on efficient data exchange and a value-based tiered care payment strategy to reward its best suppliers in terms of performance and quality.
Thanks to these early efforts to implement value-based care strategies, the organization is better prepared for the Covid-19 outbreak. Facilities with higher scores/higher grades are naturally better able to cope with the increasing pressure and scrutiny of nursing homes. Sadly, these facilities have severely affected these facilities. In addition, the program allows for near real-time viewing of data for each facility, including the number of advanced facility technologies deployed, certified respiratory staffing and training levels, ventilator weaning rate, service availability and hospitalization rates for high-risk ventilator dependents ——All the key data points when evaluating how to allocate resources.
We are at an important crossroads in healthcare. Interoperability has risen to the forefront, providing providers and payers with the information needed to implement value-based care models. Looking ahead, the key will be to ensure that the organization has the right technology to quickly adapt to any future CMS interoperability rules and continue to transfer quality results to value-based care.
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