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Timely data exchange between payers and providers is key to reducing care costs, improving outcomes


Success of value-based care programs depends on getting the right information to clinicians when it’s needed

Health care is on the cusp of a pricing crisis. The Advisory Board reports that hospital expenses are up more than 25% since 2020 and salaries are up nearly 10% in the last year. The Advisory Board also reports that while hospitals typically request price increases of 4% to 6% per year, this year’s requests are expected to be twice as high, mostly because government reimbursements are not expected to increase. Payers and employer groups are signaling they may not pay.

Rethinking strategy on efficiency and operations may seem like the only way to combat the inflation challenge, but it doesn’t need to be. Research has shown that the decisions clinicians make – from care pathways to prescriptions to lab and imaging tests – account for most health care spending. Providing clinicians with actionable information and decision support at the point of care can have a significant impact on overall care costs while positively impacting care quality – and addressing all-too-common conflicts over pricing. Insight plays as much a role as efficiency.

But there are two major obstacles: presenting the right information to clinicians and presenting it at the right time. When this doesn’t happen, decisions can be made that could increase patient care costs – referrals to out-of-network specialists, for example, or prescribing drugs not on a formulary. Clinicians can miss opportunities to close care gaps or address conditions they may not know a patient has. Not only do these scenarios have the potential to increase costs, they also stymie value-based care success.

Value-based care is difficult with a narrow view of data

Payers and providers that in a value-based contract share the goals of managing care quality, costs, and outcomes for a given population. Unfortunately, access to and impact of available patient and member data remain significant hurdles.

One part of the problem stems from how value-based care programs are communicated to care teams. There is no shortage of highly effective, purpose-built applications for managing particular populations. But the more time a care team spends toggling between apps and browser tabs during a patient visit, the less time they can spend with the patient – and the more time they devote to documentation after the appointment. This only contributes to frustration and burnout among clinical staff.

Another part of the problem can be traced to the fact that while value-based care has grown more widespread, there are a growing number of measures and approaches to performance: MSSP, PCMH, HEDIS, STARS, CAHPS, MIPS, APM, and more. And as more payers and providers have built value-based programs, and more apps and services have emerged to manage these models, the complexity of value-based care has intensified. So too has the number of potential performance metrics, as well as the number of applicable data feeds coming from each payer.

As a result, a practice may manage groups of patients covered under many value-based care agreements. Under these circumstances, it becomes difficult to know which quality, care gap, or risk metrics may apply, or which clinical services or therapies are included under a given contract. Down the line, practices face the onerous task of attesting which patients are covered by which programs, as well as determining and calculating the various quality metrics that apply to each contract.

Faced with these challenges, many practices have concluded that the cost of establishing data management infrastructure – in time, money, and resources – exceeds the benefit of participating in value-based agreements. This is a missed opportunity for all stakeholders in the health care system. Fortunately, it is a problem that can be addressed.

The benefits of bidirectional data exchange on a federated platform

The key to payers and providers successfully sharing risk in value-based care contracts is bidirectional data exchange, centrally managed on a platform that links disparate systems. This helps both entities better understand how resource utilization impacts the total cost of care and see where change is needed to keep spending in check. Understanding how each of these components operates on its own helps to explain why this makes for such a powerful combination.

Bidirectional data exchange offers payers and providers access to each other’s relevant data sources.

  • With access to clinical data, payers can calculate scores for quality programs like Healthcare Effectiveness Data and Information Set (HEDIS) or CMS Stars Ratings, as well as risk adjustment programs. This alleviates an administrative burden that distracts providers from practicing medicine.
  • With access to a range of payer data sources, providers gain additional sources of information about the patients they see, tailored specifically to the value-based care program in which they are enrolled. This insight into care gaps and diagnoses previously reported to CMS leads to more informed decision-making at the point of care.

A federated data platform enables disparate systems to exchange data using open application programming interfaces, or APIs. The concept is similar to email, where users can send and receive messages to anyone regardless of domainData can be exchanged electronically and at the moment of care. This all but eliminates the lags in sharing data between payers and providers that can often last for weeks.

  • Data from multiple third-party applications can be available without expensive and time-consuming custom integration efforts. This breaks a barrier to entry for providers who may be hesitant to participate in value-based care because it requires managing an abundance of point solutions for population health management.
  • Bidirectional data exchange on a federated data platform gives payers a single connection point for clinical data that would otherwise need to be collected and aggregated manually. It also makes it possible to surface relevant payer data in existing electronic health record (EHR) workflows, eliminating the need to leave the EHR and log into another system to view other data sources. This combination of automated documentation and clinical decision support lets payers and providers work more effectively toward their shared goals.

Additional opportunities from improved care coordination

Improved care coordination through data-driven decision-making is only the beginning, however. Greater visibility into patient- and population-level performance in value-based care will allow payers and provider groups to better meet the needs of those they serve.

One possibility is care coordination at the payer level. By diving into the deep data set available on a federated platform, payers and providers can collaborate to determine clinical best practices as they relate to value-based care models. This will make it possible to tailor decision support recommendations at the point of care to specific risk and quality metrics within a particular value-based care program.

Another opportunity is addressing social determinants of health through the non-clinical services that payers increasingly offer as covered benefits. Many providers maintain lists of community-based organizations offering these services—but it’s often up to patients to do the legwork to get assistance. If providers can refer patients to these services as easily as they can make referrals to specialists in their typical ordering workflow, they can make significant progress in closing care gaps.

Finally, this evolution may make it possible for smaller practices – even individual providers – to participate in value-based care arrangements. One of the greatest barriers to participation has been access to relevant, comprehensive data that can inform care decisions, in large part because of the infrastructure investment that’s required.

By connecting these clinicians to a bi-directional data flow, they gain insights that may previously have been available only to larger organizations. Access to actionable insights within clinical workflows and in the context of patient encounters makes it possible for all providers, regardless of practice size, specialty or affiliation, to proactively participate in value-based care and achieve performance that improves clinical and financial outcomes.

Palantoni is vice president of product management, platform services, for athenahealth

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