By Shyam Manoj Karunakaran, executive vice president of health plans, CitiusTech.
While VBC (Value based care) is the current focus point for the healthcare industry, it is important for organizations in this sector to ensure successful and efficient management in VBC. In this article, I would like to draw your attention toward the challenges in effective contract management and how best to overcome these.
Path to value for Value-based Care
The growing markets in healthcare are now centered around government-sponsored programs like Medicare Advantage (MA), the Affordable Care Act (ACA) marketplaces, and Medicaid. This trend is steering healthcare organizations towards more direct patient engagement and the management of high-risk, high-acuity patients. As healthcare organizations increasingly focus on Medicare Advantage, ACA, and Medicaid, they encounter a unique set of challenges, encompassing system integration, data interoperability, and effective data handling, among other critical aspects.
Addressing the SaaS Sprawl
Over the years, healthcare organizations have made significant investments in a variety of SaaS solutions to facilitate their day-to-day operations. These solutions, each housing data in different data centers or cloud environments, have become integral to their business processes. However, as the focus intensifies on managing high-risk and high-acuity patients, along with an increased emphasis on direct consumer engagement, there arises a critical need to integrate data and processes across this sprawling landscape of disparate SaaS systems. This integration is essential for a holistic view of patient care and efficient service delivery.
In today’s U.S. healthcare system, patients often find themselves in a perplexing situation where the quality of clinical care can be excellent, but the overall patient experience may fall short.
As the system increases its focus on value-based care and improved health outcomes, the patient experience and value-based care must be considered as interconnected entities. In fact, three value-based care quality metrics—patient satisfaction, preventive care screenings, and care coordination—are directly impacted by the overall patient experience.
The good news is that there are a number of digital tools that can play a pivotal role in fostering better awareness, comprehension, communication, and overall better care experiences. These enhancements ultimately translate into tangible benefits to support value-based care.
Empowering Patients Through Information
According to the 2023 PatientPoint Patient Confidence Index nearly half (48%) of Americans report feeling anxious before healthcare visits (an increase from 39% last year). This anxiety can be attributed to factors such as insufficient information and education, limited knowledge about healthcare providers, and hesitation to discuss health concerns with providers. Additionally, a third of Americans admit to regularly leaving appointments confused. Taken together, these anxieties hinder effective care.
When thinking about factors that could enhance their confidence in discussing their health, more than half (55%) of Americans highlighted the importance of receiving health education during appointments. Another 43% expressed interest in pre-visit education to increase confidence. Given that most patients spend approximately 14 minutes in the waiting room and an additional 12-13 minutes in the exam room without an HCP present, substantial opportunity exists to educate and empower patients while they wait.
Providers can maximize patients’ time in their offices and support value-based care by leveraging digital signage to disseminate relevant health information. Showcasing digital content in the waiting room prepares patients for important healthcare decision-making moments before they enter the exam room and has been proven to drive patient utilization of vital health services including mammography, colon cancer screening, flu vaccination, tobacco cessation counseling, and STI screening. The more personal nature of the exam room environment enables digital signage to deliver tailored information to patients, further motivating them to engage with their providers and take proactive steps for their health such as utilizing patient portals, scheduling preventive screenings and vaccinations, or discussing new treatment options.
Vytalize Health, a leading risk-bearing provider enablement platform, announced it has closed $100 million in funding led by Enhanced Healthcare Partners and Monroe Capital, with participation from North Coast Ventures. The new capital will advance its responsible value-based care for seniors proposition by strengthening primary care practices.
“We have a responsibility to ensure the ongoing success of value-based care by building high-performing systems of care that truly advance quality, improve the patient experience, and are sustainable for providers and the system overall. We believe primary care is a key part of the delivery system and that we must protect and reward independent primary care physicians who deliver more data-driven and effective care to patients. In this outcome-based environment, we can focus on real, proactive health care vs. sick care and align our model with what’s better for patients,” said Faris Ghawi, Vytalize Health co-founder and CEO.
Decisions made in the primary care setting have an important impact on healthcare quality and spending, given that primary care physicians influence a significant portion of downstream utilization, including that of specialists, hospitals, and ancillary service providers like home health agencies and nursing homes.
Vytalize Health partners with primary care practices for more than 250,000 patients and offers evidence-based recommendations at the point of care. By delivering the right data at the right time in the workflow to physicians and their staff, Vytalize makes practices more efficient and effective. The platform provides financial incentives to practices that follow recommendations and drive better health outcomes for patients.
Vytalize Health’s approach to improving access to high-quality care also includes operating a virtual and in-home clinic. The organization has launched several initiatives over the past few years, such as the Priority Care program, which leverages data to identify patients with the greatest needs. This program extends the practice’s reach to patients’ homes and incorporates social, economic, and other non-clinical factors in their environment, taking a holistic approach to care.
If you are reading this, you already know that the fee-for-service model conflicts with the delivery of quality healthcare and the ongoing optimal management of chronic conditions. The model incentivizes the quantity of services rendered and disincentivizes preventive care. As a result, fee-for-service is highly inefficient for payers and not aligned with the sustainability of healthcare delivery systems.
Value-based care has presented a better model for providers, payers, self-insured employers, and patients alike. However, it was not until recently that value-based care was positioned for adoption at scale. The challenge in adoption has always been the realignment of financial incentives and focus on long-term optimization of patient outcomes. New technology platforms have had to evolve to the point they enable fully integrated analytics, population health management, and administrative capabilities to realize the transformational opportunity we have in front of us.
Value-based care is the path to translating early intervention into healthcare savings. In 2016, a study on primary care spending in the United States showed total healthcare costs increased from $810 billion to $1.6 trillion.Specialty care accounted for 75% of healthcare spending in the United States. According to the CDC, four in 10 Americans have two or more chronic conditions requiring continued treatment by specialists.
Comprehensive value-based care requires identifying health risks and chronic conditions early. It necessitates consistent monitoring of an individual’s health and the earliest possible interventions through primary care, and specialists when necessary. In value-based healthcare, getting patients to high-performing specialists, backed by clinical outcomes data, must be prioritized to avert severe conditions and their corresponding high costs. Early intervention is proven to drive the most optimal patient outcomes while significantly reducing cost. Meaningful, specialized intervention is one of the most powerful strategies for saving lives—and therefore, it should be at the heart of advancing healthcare.
Value-based Models are Ready for Adoption
Why isn’t there complete adoption of value-based care, given its alignment with patient outcomes and cost reduction? The factors are varied, but the perceived financial risks and lack of technology enablement have held back adoption – until now.
By Christina Perkins, NaviNet vice president of product management and strategy, NantHealth.
Efficient and effective ways of exchanging information between patients, providers and payers have become even more important during times of crisis, like the COVID-19 pandemic, with a greater demand for urgent, high-quality care. Physicians need more time to devote to saving lives as the healthcare system is overwhelmed with patients and still bogged down by administrative tasks.
According to Sage Journals, the average doctor spends about 8.7 hours per week on administrative tasks, which amounts to nearly a full work day. With the current pace of the pandemic paired with the need for maintaining preventative healthcare through regular appointments, such as physicals or cancer screenings, physicians need as much time as possible to pay attention to the task at hand: patient care.
Technology is the powerful tool necessary to streamline physician workflows by increasing efficient, effective communication between payers and providers in order to determine the most appropriate treatment plan for an individual patient based on their condition and health plan. One such workflow that can oftentimes be quite time-consuming for payers, providers and patients due to disputes or other disagreements around a therapeutic path is prior authorizations.
Streamlining the prior authorization process can alleviate the burden for all stakeholders, reduce delays, and offer providers and their patients confidence they are getting the most appropriate care with the highest chance for success. With the right technology in place, prior authorizations can be streamlined greatly.
Leveraging electronic tools to enhance administrative workflows can make it clear to providers when and why a prior authorization is required, what information is needed for each kind of service, and which services are within the guidelines for treatment.
By implementing digital technologies to streamline processes like these, there is a greater reduction of time and money spent to arrive at the best possible treatment plan – bringing about a new era of value-based care. Giving doctors tools they need to efficiently get tedious administrative tasks done will greatly improve the treatment process for all stakeholders. This is the gateway into enabling true value-based care.
Interoperability also plays a critical role in uplifting value-based care by boiling down the superfluous tasks, reducing heavy administrative lifts for providers. Allowing a range of healthcare information technologies to exchange, interpret and use data cohesively consistently leads to higher quality care by relying on a value-based and evidence-based care system. There are three foundational ways in which efficient and effective exchange of information through the use of technology can be extremely valuable to the healthcare system, including:
With the shift towards value-based care reimbursement models, it has become even more important for providers to be able to digitally share patient clinical documentation with payers and other providers in a timely and reliable manner. Yet, despite administrative functions backing clinical care provision, both providers and payers have not actively explored new technologies to streamline and improve data exchange and processing workflows.
Manual, error prone document exchange methods plague healthcare. Fax is the most common secure communications protocol that providers use to electronically transmit patient documentation to health plans and other care facilities, leaving the recipient with a paper document that needs to be processed manually. Other methods of information exchange are available, but healthcare organizations often feel they don’t have a good, reliable alternative to paper-based faxing due to, in part, familiarity and comfort level with the technology.
When providers communicate the medical necessity of services to commercial health plans and government payers, they must do so within tight turnaround times. Failure to meet the submission deadlines can result in care delays for patients as well as denial or reduction in payment to providers. Additionally, comprehensive and timely communication is vital when executing proper transitions of care, where key patient information has to be part of the referral process to ensure optimal clinical outcomes.
Payers, on the other hand, spend hundreds of labor hours processing documents. CAQH CORE gives an example of a plan needing 792 labor hours, the equivalent of nearly 20 people working full-time, to process the attachments it receives by mail, fax and web portal in the course of just one week, presenting an enormous administrative burden. Only 6% of medical document attachments are processed using a fully electronic method. If all paperwork were processed electronically, the healthcare industry per-transaction costs could be reduced by over 60%, according to CAQH CORE.
Digitizing exchange and processing of medical documentation with the evolved fax and document processing tools can deliver numerous benefits to all healthcare stakeholders. Cutting down on manual document handling will ensure care is being delivered quickly and providers are adequately reimbursed. Payers can improve operational efficiency and handle claims and medical documentation faster.
Additionally, a more streamlined, electronic medical attachments exchange among payers and providers is the right step toward interoperability today because it will help break the data silos of separate clinical and administrative systems. The fluid exchange of clinical documents needed for claims adjudication, prior authorization and quality measure reporting is essential for value-based payment success. It could facilitate earlier identification of patient risk factors, reduce the time and effort associated with quality measure reporting and ease the adjudication of value-based payments.
Innovaccer is a healthcare technology company pioneering the Data Activation Platform that’s helping the industry realize the promise of value-based care.
Innovaccer’s integration & analysis engine activates healthcare data, cleaning, aggregating and delivering insights at the moment of care. This revolutionary technology streams analytics with custom insights and dashboards, automates workflows, provides real-time decisions for care teams, and point-of-care alerts—actionable intelligence without leaving the EHR experience.
Innovaccer is based in San Francisco with offices across the United States and Asia.
What is the single-most innovative technology you are currently delivering to health systems or medical groups?
Innovaccer is a leading healthcare technology company that deploys its FHIR-enabled Data Activation Platform to help the healthcare industry realize the promise of value-based care. The name “Innovaccer,” is, in fact, a play on the words “innovation” and accelerator.”
Innovaccer leverages AI and predictive analytics to generate insights that help healthcare organizations achieve better clinical outcomes. The FHIR-enabled Data Activation Platform is built on a Hadoop-based Big Data repository with a scalable architecture that allows the integration of disparate sources of data without having to write code. Its agile and modular structure can ingest structured, semi-structured, unstructured data, pool it as a single source of truth, and work on a central HL7 FHIR-based data schema.
How is your product or service innovating the work being done in the organization to provide care or make systems run smoother?
Innovaccer’s smart FHIR-enabled Data Activation Platform has intelligent workflows powered by unified patient records, advanced analytics and true interoperability, enabling collaborative healthcare. Innovaccer brings the data and all healthcare stakeholders together and empowers them with complete patient information to help them care as one.
Today, Innovaccer’s COVID-19 Management System uses AI to optimize the provider response to the disease, allowing medical facilities to reduce assessment time and prioritize patients with a high-risk profile for the next steps of care.
By Lisa Hebert, director of product management, NantHealth.
Our industry is stuck in an inefficient, costly trend—treating avoidable diseases rather than preventing them. According to the Centers for Disease Control and Prevention (CDC), chronic diseases, such as diabetes and heart disease, account for 75 percent of our nation’s healthcare spend. Shifting our focus to wellness will improve patient health and reduce overall healthcare costs.
How do we get there? A transition to preventative care requires value-based care that is aimed at the long-term needs of individual patients. Patient-centric and evidence-based, the model leverages vast amounts of historical healthcare data and advanced analytics to provide clearly defined routes to well-established, evidence-based treatments with proven effectiveness. It helps providers assess risks, benefits, and trade-offs of specific treatments, avoid unnecessary treatments and costs, and deliver more accurate, better quality care that keeps patients healthy throughout their lives.
Value-based care benefits all participants—healthcare providers, facilities, and plans, and the patients they serve. It’s dependent on active, ongoing participation from all parties. Collaboration is critical to its success.
Leveraging Technology to Collaborate
A value-based care system requires robust technology to replace manual tasks, reduce inefficiencies, and support the transfer of patient data in a secure, timely and comprehensive way. Done right—interoperable and seamlessly integrated with existing workflows—automation technology can enable patients, providers and payers to communicate and collaborate in meaningful ways, while saving significant costs. It is estimated that the industry could save $12.4 billion by fully adopting electronic transactions that enable them to exchange vital information in near real-time and more readily communicate and collaborate to deliver care with delay.