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5 considerations for overcoming obstacles in the shift to value

The journey to a value-based healthcare payment model is further away than we think. The AMGA’s recently released Fourth Annual Survey, Taking Risk, 4.0: Clearing a Pathway to Value-Based Care, lists many obstacles.

Even after a decade of programs, incentives and infrastructure investments, the federal payment plans are tipping the scales with 56% of healthcare revenue aligned with care delivered via fee-for-value programs. The commercial plans are woefully behind that, with a whopping 72% of revenue still based on fee-for-service programs.

Similar to results from the past three years’ surveys, AMGA members noted ongoing obstacles in moving to value. Here are the 5 considerations (and the Allscripts contributions) for overcoming the 15 impediments to taking on risk.

1. Attribution methodology

Providers are paid based on the list of patients that are attributed to them by the healthcare plan. Healthcare plans “attribute” their members (the patients) to specific providers. When these lists don’t align, providers don’t get credit for the care (and reporting) they delivered to the patient (i.e. member) and therefore will score lower in value-based care models.

An exception to the attribution problem is the Medicare Advantage participants. Because members (patients) enroll in an MA plan, attribution to the provider is clear. This is perhaps one reason why MA is the most prevalent risk-payment model for federal plans.

Allscripts helps with payer systems partnership and integration to create custom attribution reconciliation reports and recommended data governance needed to manage these lists.

 2. Access to full claims information

As a provider, you are constantly solving a puzzle. Information from various sources is pulled together to give the full picture of health or risk. The single source of truth for all this information lives within the claims data.

Without full access to claims data, providers can be left with blind spots that impact diagnoses, treatment and even care management. Ultimately, patients don’t receive the care they deserve and providers are left “under delivering” within the metrics of the value-based care program.

Providers are left to send and receive data to different payers in different formats, causing large data integration needs.

Pulse8, part of the Allscripts VeradigmTM business unit, provides granular analytics (output files, chase lists, dashboards and reports) at both the member-centric and provider-centric levels. Member-centric analytics are available within Qualit8 and Calcul8, whereas provider-centric analytics are also contained within Collabor8. Together, Pulse8 pairs the most piercingly accurate Risk Adjustment and Quality Management analytics with the most pragmatic interventions and provider-engagement approach available on the market.

 3. Standardize data submission

We all know the importance of interoperability. There are degrees of interoperability. Simply providing access to a consolidated clinical document architecture (CCDA) is hardly the level of interoperability needed to support the shift to value. True value from the healthcare data (clinical and claims) comes when a clean, nimble, unified patient record is made available at point of care and within managed population reporting.

The Allscripts CareInMotionTM suite can submit data across fragmented sites and integrate discrete patient data from diverse care settings, regardless of IT supplier, into a single patient record. dbMotion provides a longitudinal patient record with semantically normalized data, point-of-care tools and an analytics gateway.

 4. Lack of commercial “risk arrangements” and cost/quality feedback

In what industry besides healthcare are commercial plans far behind federal plans? There are little to no incentives for the commercial plans to provide risk-based payment models. Providers spend thousands of dollars on IT investments and care management teams not knowing the full potential or return of the risk-based models.

Allscripts partners with Quality and Analytics teams to de-code what plans are available to you in your region and that best align with your capabilities. Together we will create a plan in alignment with your values and strategic goals that will maximize the plan’s performance.

 5. Problems with the data (Medicare and health plans)

Not all data are created equal, clean or good. The best technology will not work on bad data. CareInMotion employs semantic grouping technology, making dbMotion the leader in complex medical ontologies. We also leverage a data source analysis tool to determine source data deficits and identify gaps in data integrity.

On the topic of data, the report correctly calls out the point that we are, at times, spending tremendous resources collecting quality measures that have little impact on improving quality. Models that focus on prevention, appropriate utilization, patient experience and meaningful outcomes are in line with a move toward value.

Value lies with the patient, especially because caring for the patients was the reason respondents entered the healthcare field. Risk-based payment models should allow providers the flexibility to participate in programs that matter to their local population. As plans evolve and non-clinical factors needs are considered (such as social determinants of health), program and IT flexibility will be even more critical.

Risk-based or not, the three categories of investment highlighted in this report resonate: care process redesign, IT solutions and care management personnel. These are all pillars for better care and better collaboration between providers and payers. To read the full report, click here.

Thank you to the AMGA for conducting this survey for the fourth consecutive year. I leave you with this final question and truly would like to hear your thoughts: Are risk-based payment models really the pathway to value-based healthcare?

Comments 1

  1. Kenny Chon 09/08/2019

    This site certainly has all the information I needed about this subject and didn’t know who to ask.

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