Health plans own the back-end technology that powers the value-based models and patient insights that will enable more equitable care.
In an uncertain economy, providers, payers and patients will turn to value-based care models to reduce costs and improve health outcomes.
These models, in which reimbursement is rewarded based on the quality of care, have returned to the center of the health debate.
During the pandemic, the industry has seen a rapid shift to these pay-for-performance models, with one major healthcare provider rapidly deploying a value-based care model in just 18 months, according to a recent analysis by McKinsey & Company. This analysis also finds that even as investments in digital health have declined since 2021, private equity firms continue to bet on innovative healthcare business models that deliver positive outcomes, showing promise for accelerating the adoption of data-based care. value.
As COVID-19 has brought value-based care back to the stage, health plans must now put the spotlight on this model of health care delivery moving forward. How come?
Health plans hold the keys to the back-end technology that powers these value-based models, the patient insights that will enable more equitable care, and the systems that will enable seamless data exchange across the healthcare continuum.
Unlock data insights to drive health equity
To carry the value-based care torch forward, health plans need to unlock the data.
For years, healthcare leaders have debated the need to consider the social determinants of health (SDOH) – the factors outside the doctor’s office that influence care – in how care is delivered to each patient. By integrating this data into patient care plans in a value-based care model, health plans can better assess patient health risks and help providers proactively support patients.
Data aggregators like LexisNexis have developed the tools to collect SDOH data. The challenge is that this data is often stored in silos or handed over to providers too late in a patient’s care journey. Looking ahead, health plans will need to leverage technology solutions that can automate and scale their value-based care programs with SDOH data pulled from aggregators and disseminate this information to all healthcare providers impacting a patient’s care.
This work is already in progress. Innovative Management Solutions of New York (IMSNY), a joint venture led by large behavioral health practice associations, is pioneering SDOH data integration.
IMSNY built an SDOH solution centered around three components: a local community-based support map for patients, a data warehouse that brings together clinical and community-based patient data, and a curated network designed to conduct closed-loop reporting to ensure the customer receives the indicated service. This program has enabled patients to receive health care for the whole person, leading to better health outcomes.
Enter the new technology to scale
To transform value-based care infrastructure with new SDOH dataflows, health plans need to look closely at the technology they innovate with.
The reality is that value-based care started out as an experiment. In its early stages, health plans developed value-based care models through in-house solutions, huge spreadsheets, and labor-intensive manual processes. Compounding the problem, legacy claims and payment systems built for paying for service are, at best, marginally capable of supporting value-based payment and service models.
Now, as more and more vendors are open to adopting these risk-based cost models, the challenge is to modernize these legacy systems to handle an influx of new value-based service contracts while still coordinating legacy contracts.
To do so, health plans are increasingly looking for technologies that can optimize value-based care programs to improve year-over-year performance. Health plans need technology that standardizes and automates value-based programs and adapts to the contractual needs of providers.
These technologies must fundamentally support data aggregation, governance and quality, a modular and reusable IT infrastructure, better policy support and compliance, better information sharing capabilities, and a framework to support better value and outcomes.
Open the door to provider communications
As health plans modernize their technology stack to scale their value-based care systems, improved communication with providers will be critical. Historically, value-based support has been an opaque system for some vendors with uncertainty about how they are performing on a contract.
This lack of transparency ultimately slows the adoption of value-based care as providers are unsure if they should or can hire new members. Health plans must provide a larger window into provider performance.
There is also a need for more clarity for providers on how to send patient care data to the health plan. For many plans, this process is still very fragmented with vendors sending data from various channels. Restricting supplier data flow to one channel with technology that can provide rapid insight into this data will be the future of value-based support.
Health plans are the guardians of value-based care. SDOH data integration, improved technology infrastructure, and greater transparency in the provider data flow will be key to promoting value- and equity-based care.
Dr. Abhishek Jacob is the Vice President of Product Management at Edifecs, where he leads value-based care product offerings. Fred Guthrie is an associate vice president of Edifecs and is the product owner for the company’s population payments management business.