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.
U.S. Department of Health and Human Services (HHS) Secretary Alex Azar and Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma announce the CMS Primary Cares Initiative, a new set of payment models that will transform primary care to deliver better value for patients throughout the healthcare system. The CMS Primary Cares Initiative will aim to reduce administrative burdens and empower primary care providers to spend more time caring for patients while reducing overall healthcare costs, HHS said in a statement.
“For years, policymakers have talked about building an American healthcare system that focuses on primary care, pays for value, and places the patient at the center. These new models represent the biggest step ever taken toward that vision,” said HHS Secretary Alex Azar. “Building on the experience of previous models and ideas of past administrations, these models will test out paying for health and outcomes rather than procedures on a much larger scale than ever before. These models can serve as an inflection point for value-based transformation of our healthcare system, and American patients and providers will be the first ones to benefit.”
Empirical evidence shows that strengthening primary care is associated with higher quality, better outcomes, and lower costs within and across major population subgroups. Despite this evidence, primary care spending accounts for a small portion of total cost of care, and is even lower for patients with complex, chronic conditions, HHS said.
CMS’s experience with innovative models, programs and demonstrations to date have shown that when incentives for primary care clinicians are aligned to reward the provision of high-value care, the quality and cost effectiveness of patient care improves, the organization cited.
“As we seek to unleash innovation in our health care system, we recognize that the road to value must have as many lanes as possible,” said CMS Administrator Seema Verma. “Our Primary Cares Initiative is designed to give clinicians different options that advance our goal to deliver better care at a lower cost while allowing clinicians to focus on what they do best: treating patients.”
Administered through the CMS Innovation Center, the CMS Primary Cares Initiative will provide primary care practices and other providers with five new payment model options under two paths:
Primary Care First and Direct Contracting.
The five payment model options are:
Primary Care First (PCF)
Primary Care First – High Need Populations
Direct Contracting – Global
Direct Contracting – Professional
Direct Contracting – Geographic
The Primary Care First (PCF) payment model options will test whether financial risk and performance based payments that reward primary care practitioners and other clinicians for easily understood, actionable outcomes will reduce total Medicare expenditures, preserve or enhance quality of care, and improve patient health outcomes. PCF will provide payment to practices through a simplified total monthly payment that allows clinicians to focus on caring for patients rather than their revenue cycle. PCF also includes a payment model option that provides higher payments to practices that specialize in care for high need patients, including those with complex, chronic needs and seriously ill populations (SIP).
Both models under PCF incentivize providers to reduce hospital utilization and total cost of care by potentially significantly rewarding them through performance-based payment adjustments based on their performance. These models seek to improve quality of care, specifically patients’ experiences of care and key outcome-based clinical quality measures, which may include controlling high blood pressure, managing diabetes mellitus and screening for colorectal cancer. PCF will be tested for five years and is scheduled to begin in January 2020. A second application round is also planned for participants starting in January 2021.
Now more than ever, the healthcare industry is leveraging new technologies to provide patients with improved, innovative care. The innovation attracting the most buzz in the healthcare industry today is artificial intelligence (AI). However, despite the ongoing hype of robots and algorithms as industry game-changers, results to date from early applications of AI in healthcare have fallen short of realizing dreams of sweeping improvements.
IBM’s Watson is an excellent example of how these improvements “in healthcare” will require a more step-by-step approach and may take longer to achieve than initially thought. In 2011, Watson garnered worldwide attention by winning a game of Jeopardy against two of the show’s greatest champions. Within healthcare, Watson’s win gave rise to hope that AI was on the precipice of full-scale deployment that would transform the industry and dramatically improve patient outcomes.
For several reasons, that hasn’t quite happened yet, and Watson has found it challenging to deliver improved patient outcomes. While those critical of AI have been quick to jump on these struggles, it’s crucial to acknowledge that Watson suffers from several common obstacles faced by AI in healthcare. These include the lack of high-quality data that can be used to train an algorithm, the low number of available training cases, implicit bias, and the differences in guidelines between the U.S. and other countries.
However, as the industry collectively works to address these issues, I envision three major areas where AI will soon transform personalized medicine.
Individualizing the patient-clinician relationship
Clinicians are already equipping themselves to better serve their patients with the predictive and organizational benefits of AI. This technology will move the field away from a “one-size fits all” approach and make the clinician-patient relationship more individualized, fostering trust.
This would be no small feat for improving the patient-clinician relationship, especially for those suffering from chronic conditions. A study by West Corporation in 2018 found that only 12 percent of chronic condition patients feel strongly that their provider is doing a good job of delivering information specific to their needs and condition.
When a clinician provides patients with unique, individualized solutions, patients feel empowered and are more comfortable speaking up throughout the treatment process. When a patient is comfortable enough to report symptoms, no matter how trivial they may seem, personalized medicine thrives.
With the help of AI, clinicians can search extensive amounts of information to find the causes of patient-reported symptoms and alter patient care accordingly. These improvements can be referenced by other clinicians and lead to large-scale medical breakthroughs.
By Rick Halton, vice president of marketing and product, Lumeon.
For the past decade, EHR investments have been touted as the key to unlocking a transformative, cost-effective, and efficient healthcare industry. A recent study found that spending on EHR systems will continue to dominate healthcare’s technology spend in 2019. But if budgets continue to be prioritized towards optimizing EHR systems, why are there still so many issues related to delivering coordinated care? EHR vendors often do not clearly explain that new issues can arise after implementation, and even make certain processes more complex.
Despite significant investment of EHR systems over the years, care processes continue to be inconsistent and labor intensive. Not only does this result in overwhelming operational costs for hospitals, but it also leads to massive variance in outcomes.
EHR investments are important, but they aren’t a silver bullet. EHRs can only go so far towards improving care outcomes and operations, as they do not address the true problem: disjointed care process issues. Hospitals must consider the broader context that EHRs play into, including investing in greater orchestration and automation of patient care.
By directing investments toward automated digital care plans that are supported by EHRs, hospitals can more effectively connect patients along their entire care journey, and only engage the care team when necessary. Just as the airline industry found success with their equivalent, the “flight plan,” the healthcare industry must provide its own “care traffic control” to deliver coordinated care. This approach is increasingly recognized as care pathway management (CPM).
Opting for “care traffic control?”
The airline industry has successfully crafted and fine-tuned the entire digital trip experience for passengers, which the healthcare industry can utilize in its own way. For example, airline passengers can find out real-time flight status, receive automated updates about seat availability, find information on airports, and be sent data on flight delays.
Both boarding and takeoff are efficient and seamless procedures, with airlines connecting preflight checklists to central airline and airport IT systems. This gives flight crews current policies, procedures, and alerts, while traffic control systems coordinate which planes can take off at which times.
This same approach can effectively be used in healthcare. Automated protocols throughout the care plan can help providers pull relevant information from all necessary care teams and orchestrate operational processes in the background. Tasks can be completed in an efficient and timely manner, with managed expectations creating a seamless care pathway.
With a “care traffic control” approach, care teams manage by exception. Care plans are digitized, automated, and orchestrated across teams and settings, letting care teams be efficiently tasked at the right time and at the right place. Additionally, care teams can capitalize on virtual patient engagement techniques and will intervene only when manual engagement is needed.
In the seventh annual Health IT Industry Outlook Survey conducted by Stoltenberg Consulting Inc., 42 percent of health IT leaders rate updating technology to improve the patient experience as the top objective for 2019, followed by measuring improvement in patient care (33 percent).
Coinciding with this pivotal focus on empowering the patient care journey, 45 percent of respondents identify value-based care as the most significant, pressing topic in healthcare this year, followed by artificial intelligence (26 percent) and cybersecurity (20 percent). Meanwhile, leveraging meaningful patient data (32 percent) serves as the largest overall hurdle for health IT teams in 2019, followed closely by ineffective IT or EHR operations (29 percent).
In the push to gain true value in value-based care initiatives, lack of system interoperability stands as the biggest operational burden for healthcare organizations (54 percent), followed by rising overhead and staff costs (17 percent), financial reimbursements (15 percent) and EHR burnout or reporting burden (14 percent).
“Thanks to the continuing industry push for healthcare interoperability, significant progress is starting to come to fruition,” said Dan O’Connor, vice president of client relations at Stoltenberg Consulting. “We’re now seeing a clearer picture of how different players across the care spectrum will be held accountable to drive more transparent, engaged patient care journeys, which in turn will help healthcare providers meet their organizational goals.”
Other key survey findings indicate that despite nearly universal initial adoption across the country, EHR and application implementation support (34 percent) remains the top 2019 IT outsourcing request, followed by optimization work (27 percent), legacy system support (22 percent) and help desk support (17 percent). Yet, with current IT training offered, 63 percent of respondents say they feel “unprepared” or “very unprepared” to manage and execute effective IT operations within their healthcare facilities.
Stoltenberg conducted the survey at the 2019 Health Information and Management Systems Society (HIMSS) annual conference in Orlando. More than 300 survey participants represented a comprehensive spectrum of provider facilities, including health systems, standalone hospitals, physician practices and other ambulatory care facilities. Clinical IT professionals led survey participation (38 percent), while executive/C-suite leaders followed closely behind (36 percent).
New data on the state of value-based care in oncology has found that while community oncologists are optimistic about the beneficial potential of value-based care, they see a conflict between the need to decrease episode costs and the rising prices of the most innovative novel therapies.
In an effort to dig deeper into current attitudes toward new value-based reimbursement models and novel therapies in cancer care, Integra Connect surveyed leaders and decision-makers in oncology practices. Respondents represented practices with approximately 530 community oncologists, all of whom are participating in value-based care programs.
The survey results yield useful insights into how oncologists are dealing with rising drug costs in the era of value-based care, which makes practices financially accountable for improving the quality of patient care while also lowering the overall costs of cancer episodes. As drug prices continue to increase to new levels, driven in part by groundbreaking therapies, respondents indicated that it is becoming increasingly difficult to keep costs below value-based care program targets.
Other key themes surfaced by the survey include: expectations for the future of value-based cancer care; how drug costs are affecting treatment behaviors; what oncologists need from pharmaceutical manufacturers; the influence and effect of care pathways; and the value of and vision for precision medicine.
The number one challenge for making value-based care work: Rising drug costs
When asked about the number one challenge for making value-based care succeed in oncology, the majority of respondents (57 percent) cited managing the rising cost of drugs, including promising but expensive novel therapies. Beyond the context of value-based care, 93 percent of oncologists describe increasing drug costs as a priority issue impacting the overall well-being of their practices.
Value-based care is driving changes in cancer treatment choices
With oncologists increasingly accountable for the cost of entire episodes of care, a full 87 percent of survey respondents said that value-based care is causing them to think differently about drug choices, compared to their approaches during the fee-for-service era. When it comes to the choice of drug for an individual patient’s treatment regimen, oncologists assert that they remain as committed as ever to delivering the best clinical outcomes, regardless of impact on episode cost.
Nonetheless, more than three-quarters of oncologists indicated that they are making changes to how they and their practices choose treatment regimens under value-based care programs. A sizeable group (38 percent) says that it may change drug choices and opt for lower-cost therapies, but only when efficacy and toxicity remain the same. An equal percentage of oncologists voiced a desire to develop a deeper understanding of drug value, not just cost, that helps them understand the patient impact of therapies on an individualized level.