What You Should Know: 

– inVio Health Network and CVS Accountable Care Organization, a division of CVS Health, have announced a collaboration to participate in the new Medicare Accountable Care Organization (ACO) REACH program. This initiative focuses on improving access to high-quality healthcare for traditional Medicare beneficiaries in South Carolina.

– The collaboration builds upon the past achievements of Prisma Health Upstate and Prisma Health Midlands Networks, which merged in 2021 to form inVio Health Network. These entities have a proven track record of success in the Medicare Shared Savings Program (MSSP), another CMS program. Through MSSP, they have demonstrably reduced healthcare costs while maintaining exceptional quality of care for over 60,000 Medicare beneficiaries.

REACH Program: Reducing Barriers and Improving Outcomes

The REACH program from the Center for Medicare & Medicaid Innovation (CMMI) aims to address healthcare disparities. Participating ACOs like the newly formed collaboration between inVio and CVS will work towards:

• Reduced Barriers to Care: The program seeks to eliminate obstacles that prevent patients from receiving necessary medical attention.
• Coordinated Care: A focus on ensuring patients receive well-coordinated care across different healthcare providers.
• High-Quality Patient-Centered Care: Prioritizing patient needs and preferences to deliver exceptional medical care.
• Improved Overall Health and Satisfaction: The ultimate goal is to improve patients’ health, clinical outcomes, and overall satisfaction with their Medicare coverage.

Enhancing High Quality Patient Care

inVio Health Network, a leading physician-led network in the Southeast, brings deep local knowledge and a commitment to high-quality patient care. CVS Accountable Care contributes its extensive experience and resources. Together, they will leverage this combined expertise to:

• Enhance Care Coordination: Advanced analytics will be used to streamline care coordination for patients, ensuring they receive seamless treatment across different providers.
• Value-Based Care and Population Health Management: The collaboration will implement key programs and resources focused on value-based care and population health management. This data-driven approach allows for proactive care and improved health outcomes for the entire patient population.
• Longitudinal Care Management: The focus will be on providing patients with consistent and comprehensive care throughout their healthcare journey.

“We are on a collaborative value-based journey with our physicians and healthcare clinicians to improve the quality and health across South Carolina, regionally, and nationally,” said Dr. Bill Gerard, CEO of inVio Health Network, “This new model allows us to provide enhanced resources and clinical services across our network where we will be collaborating with MinuteClinic locations across South Carolina to be part of our network’s ACO REACH program. We look forward to the incredible opportunities ahead as we transform healthcare together.”

In the ongoing transition to value-based care (VBC), provider contracting poses challenges for health plans and providers. In my past role as the VP of Quality at a large health plan, I was part of the team that reviewed provider contracts that included risk around quality. Adding my role to the review process reduced the frustration of the Network and Quality teams because I could identify the reporting requirements that the health plan couldn’t meet and create alignment with measure priorities.

Value-based contracting rapidly evolves, with federal and state regulatory bodies imposing new mandates. The Centers for Medicare and Medicaid Services (CMS) intends to shift traditional Medicare and many Medicaid beneficiaries into VBC arrangements by 2030. The growing emphasis on quality further fuels the demand for VBC contracts as payers push for them and providers recognize their significance in driving volume and revenue.

This acceleration toward VBC results in complex contracts with intricate data management needs to achieve quality outcomes. Here’s how quality considerations and the associated data influence VBC contracts.

Understanding VBC contracting concepts

Most contracts fall along a spectrum, increasing complexity as risk sharing expands. The following are the most common contracting concepts, from minimal to more comprehensive risk sharing:

• Gainsharing: For providers just starting with VBC, they share in the savings and not the risk of loss, giving them an upside-only arrangement.
• Upside/Downside Risk Models: Providers share in both savings and risk. In these contracts, providers receive a per-patient allotment of funds and retain the defined portion of the surplus generated. However, if they spend more than the allotment, they are responsible for a specified portion of the deficit.
• Bundled Payments: The provider receives a fixed payment for all services within a single episode of care or for a specific period, such as joint-replacement surgery. If the provider successfully delivers care and prevents complications or errors, they keep a portion of the savings. However, they are responsible for the deficit if costs exceed the fixed amount.
• Capitation – Professional-Only Risk: The payer establishes risk pools, typically based on a monthly payment per member (PMPM). The amount payers give providers is based on the average expected healthcare utilization and risk profile of the patient pool, among other factors. Providers are only responsible for the professional side risk.
• Capitation – Global Risk: This arrangement is the same as the Professional-Only Risk above, except providers and payers fully share risk in these contracts.

As each party takes on financial risk, the need for VBC expertise and technology to support care and contract management increases. There are several contract considerations to help payers and providers build the proper foundation for VBC success.

Identify the best approach for all parties.

While achieving a perfect contract for all parties may be unlikely, better collaboration is more likely to result in win-win scenarios. Initial negotiations often begin with the health plan’s template, aligned to their goals, but healthcare is diverse. Providers and payers must ensure the right stakeholders are involved to ensure quality metrics are tailored to the provider’s specific patient population, such as children or diabetics. Payers and providers must also align on standards, like NCQA or CMS Core Set, so parties can determine the most appropriate risk-sharing levels, ensure the measures are reportable, and gather necessary data.

Consider how to match measures to members

Plans with multiple lines of business must consider the measures that best reflect the desired outcomes for each population and look for commonality where possible. Another consideration is, when negotiating with a provider practice, payers should consider the specialists. If the practice has an endocrinologist, it benefits all parties to have quality measures related to diabetes in the contract. 

Focus on carrots, not sticks.

The proper contract will encourage compliance through incentives rather than penalties. Payers should tie provider incentives to defined quality measures and promote ease of reporting, such as CPT 2 codes and providing supplemental data to health plans to lower the cost of data acquisition. This approach, emphasized by Jessica Columbus of Apex Health, promotes efficiency for providers, such as using point-of-care alerts to guide actions aligning with contract goals.

One data feed to rule them all 

The ongoing challenge in VBC is building the required infrastructure and technology. Complicating matters is the need for a standardized minimum data set, with health plans having differing specifications for supplemental data files. Even with standardized measures, consolidating data from multiple sources is highly challenging. Efficient use of available data is crucial for health plans to avoid frequent revisits to providers.

Consider the implications for data aggregation. Suppose a provider collaborates with seven plans, each with a distinct gap-in-care list and inconsistent header data. In that case, the payer must invest resources in consolidating this data to manage quality measures effectively.

Nick D’Ambra, former VP of Quality Improvement at AbsoluteCare, shared an essential experience at the RISE HEDIS & Quality Improvement Summit. While working on a state-mandated performance improvement project to streamline clinical practice guidelines, the central question emerged: Could a broader opportunity exist to collaborate with other managed care organizations and create a unified file format meeting all their needs?

Bridging the data management gap 

Collecting and reporting data for Value-Based Care (VBC) is challenging, especially with the increasing volume of data as VBC becomes more common. However, the impact of AI technologies like machine learning, natural language processing, and optical character recognition, including generative AI like ChatGPT and Bing Chat, is significant. These technologies excel at aggregating and synthesizing patient data from various sources.

Unlike spreadsheets, which require manual input and manipulation, health plans can automate AI to operationalize data intake and tasks, identify patterns, highlight relevant information, and streamline processes. For payers and providers managing quality measures in contracts, leveraging data both prospectively and retrospectively is crucial, and AI enables this at scale. 

Winning at VBC

Organizations that effectively leverage AI to precisely identify, monitor, and report quality outcomes will position themselves for success in attaining value-based contracts, thereby enhancing patient health and bolstering financial performance.

About Elissa Toder, MBA

Elissa Toder, MBA, is the Vice President of Quality Improvement Strategy & Solutions at Reveleer. Elissa holds a BS in Health Policy Administration from Penn State University and earned her MBA at Clark University.

What You Should Know:

– Medical Home Network (MHN), a leader in transforming care in the safety net, announced today its partnership with 64 federally qualified health centers (FQHCs) across seven states. These FQHCs will participate in two key CMS value-based care programs: ACO REACH and MSSP (Medicare Shared Savings Program).

– This expansion comes on the heels of an impressive achievement by existing MHN partners: $10.1M in gross savings and a perfect quality score in the 2022 performance year for the NeueHealth Premier ACO.

Expanding Access to Value-Based Care

2024 marks MHN’s first year in the MSSP and its second year in ACO REACH. The participating ACOs will collectively cover nearly 50,000 Medicare lives, significantly expanding access to value-based care for underserved communities.

Empowering FQHCs with Technology and Support

MHN equips FQHCs with the tools and resources needed to succeed in value-based care models. They provide:

• AI-driven analytics: Real-time insights into patient health, enabling proactive care and improved outcomes.
• Care coordination support: Building strong systems for holistic patient management across various providers.
• Technical assistance and guidance: Navigating the complexities of value-based programs.

Advancing CMS’ Vision

This expansion aligns with CMS’ goal of having 100% of Medicare beneficiaries in accountable care relationships by 2030. As FQHCs serve a growing number of Medicare patients and play a vital role in the safety net, their participation in value-based programs is crucial to achieving this vision. This newly formed MSSP ACO includes 17 FQHCs across five states, with Cheryl Lulias serving as CEO. This collaboration signifies MHN’s commitment to expanding its reach and impact.

“Since our founding in 2009, MHN has believed that supporting community health centers is the key to building healthier communities. Enabling their participation in these value-based care models is a natural extension of our mission, and we’re thrilled so many forward-thinking organizations have trusted us and our proven care model to help them on this journey,” said Cheryl Lulias, president and CEO, MHN and CEO, Medical Home Network REACH ACO.

What You Should Know:

• The Ohio State University Wexner Medical Center and CVS Accountable Care, part of CVS Health® (NYSE: CVS), today announced the creation of an accountable care organization (ACO) to improve the quality of care for Medicare beneficiaries by Ohio State providers in central Ohio.
• This coordinated approach to delivering care is centered around each patient’s unique needs and emphasizes preventive wellness and proactive treatment of chronic conditions.

CVS ACO and Ohio State Wexner Medical Center Forge Alliance to Enhance Patient Care and Coordination

The new CVS ACO, LLC (CVS ACO), operating under the Medicare Shared Savings Program (MSSP) Enhanced track ACO, expands the Ohio State Wexner Medical Center’s ACO efforts. 

This collaboration aims to enhance patient care, ensuring timely and appropriate services. By pooling resources, CVS ACO will offer coordinated care and longitudinal management, addressing both medical and social needs for a larger patient population. The Ohio State Wexner Medical Center and CVS Accountable Care teams will focus on supporting post-hospitalization transitions, providing services for high-risk beneficiaries, and strengthening overall care management. Patients will benefit from increased interaction with clinical care teams, including education on complex conditions, assistance with follow-up visits, and access to community resources.

“As we prepare for the nationwide shift to having all Medicare beneficiaries in accountable care relationships by 2030, this collaboration with CVS Accountable Care is a natural progression of Ohio State’s work in this space that builds on our commitment to provide the very best care to every patient, every time,” said John J. Warner, MD, CEO of The Ohio State University Wexner Medical Center and executive vice president at Ohio State. “It’s important that we meet every patient where they are in their health care journey and take the next step in being accountable for our patients’ holistic health and improved outcomes.”

What You Should Know:

– Medical Home Network (MHN), a leading care enablement partner for FQHCs, announced that its partners participating in the NeueHealth Premier ACO achieved $10.1 million in gross savings and a perfect 100% quality score in the 2022 performance year.

– This accomplishment, under the ACO Realizing Equity, Access, and Community Health (REACH) Model, involved 20 FQHCs across Ohio, Missouri, and Illinois serving approximately 10,000 Medicare beneficiaries. The success highlights the effectiveness of MHN’s collaborative approach and its commitment to empowering FQHCs in value-based care.

MHN’s Team-Based Care Model Drives Results

The key to this success lies in MHN’s unique team-based care model. By providing culturally tailored, whole-person care, MHN’s approach empowers FQHCs to:

Hire and train care coordinators and managers: These dedicated professionals provide comprehensive support to patients, addressing both clinical and social needs.

Leverage AI-powered risk assessments: MHN’s proprietary technology identifies patients at risk for adverse events and helps prioritize care interventions.

Utilize performance analytics: Data-driven insights guide care teams in closing care gaps, reducing unnecessary emergency department visits, and optimizing inpatient utilization.

Significance for FQHCs

With over 30.5 million Americans relying on FQHCs for their healthcare, their inclusion in value-based care models is crucial to achieving equitable and efficient healthcare for all. MHN’s success story demonstrates the potential of FQHCs to excel in this domain, paving the way for broader participation and improved health outcomes for underserved communities.

“These nationally leading results are early proof that FQHCs can benefit from our team-based model of care and thrive as they enter value-based care arrangements,” said Cheryl Lulias, president, and CEO of MHN. “This also shows ACOs led by FQHCs can achieve stellar results.”

What You Should Know:

– Clover Health, a physician enablement company committed to bringing access to great healthcare to everyone on Medicare announced that it has delivered notice to the Centers for Medicare and Medicaid Services (“CMS”) that it will exit the CMS ACO REACH Program at the end of the 2023 performance year.

– Written notification will also be sent to all participating physicians in accordance with CMS requirements.

– The decision will have no impact on its ACO REACH beneficiaries, and Clover will continue to fulfill all of its obligations under the ACO REACH Program for the 2023 performance year.

Strategic Decision to Focus on Medicare Advantage

Clover Health’s CEO, Andrew Toy, explained the company’s decision to exit the ACO REACH Program:

“When we entered the ACO REACH business in 2021, we felt that expanding our platform to Original Medicare would have a number of benefits, including increasing the number of lives under Clover Assistant management and enabling us to rapidly increase the number of physicians we worked with directly. And, while we were successful in those goals, we have not seen a clear line to profitability in this business and it has also become quite clear that, over the same period of time, we have made far greater and swifter strides on our path to profitability in our Medicare Advantage insurance business.”

What You Should Know:

• NextGen Healthcare, Inc. a leading provider of innovative, cloud-based healthcare technology solutions, today announced that its clients participating in the Medicare Shared Savings Program (MSSP) leveraged NextGen® Population Health to achieve a cumulative $82 million in total Medicare savings last year.
• The MSSP incentivizes hospitals, associations of physicians, and other healthcare facilities to form accountable care organizations (ACOs) that optimize resources to save costs and better serve Medicare beneficiaries in their communities.

NextGen’s Impact: Transformative Results in MSSP ACOs Across the Nation

In 2022, nine NextGen Healthcare clients across the nation took part in MSSP ACOs, marking the most recent year for available data. Through the implementation of NextGen Population Health, these entities seamlessly incorporated actionable patient insights into electronic health record (EHR) workflows, ultimately enhancing engagement and elevating the quality of care provided to attributed beneficiaries. With an improved capacity to pinpoint and address gaps in care, the MSSP ACOs demonstrated noteworthy advancements in quality performance. The collective outcomes for the 129,000 Medicare beneficiaries served included:

– Total Medicare savings amounting to $82 million

– Shared savings reaching $42 million

– An average shared savings of $27.85 per member per month

– An impressive average quality score of 83.9%

Hutchinson Clinic, a NextGen client catering to South Central Kansas and representing a network comprising over 100 physicians and 600 employees, actively participated in an MSSP ACO during the same period, achieving savings for their Medicare beneficiaries.

“As the healthcare landscape increasingly shifts towards value-based care, NextGen Healthcare is helping ACOs leverage data and actionable insights at the point of care to reach evolving standards of clinical and financial excellence,” said Srinivas (Sri) Velamoor, chief growth & strategy officer for NextGen Healthcare. “We are proud to support our clients’ commitment to providing high-quality and cost-effective care for Medicare patients and manage their transition to risk-based arrangements.” 

What You Should Know:

– Edward-Elmhurst Health (NS-EEH) has announced a significant, long-term partnership with Lumeris, a pioneer in value-based care (VBC). This partnership is a major development in the healthcare industry, representing the largest VBC provider deal since 2018.

– With rising expenses outpacing reimbursement rates, health systems and physician organizations are increasingly turning to value-based care to avoid layoffs and service cuts. NS-EEH, the third largest healthcare delivery system in Illinois, comprises nine hospitals, 25,000 team members, and 300 local offices, serving over 4.2 million residents.

Collaboration aims to drive coordinated care and improve quality while reducing costs

NS-EEH will strengthen its clinically integrated network (CIN) by incorporating Lumeris’ population health data platform into its value-based care strategy. The two organizations also plan to deliver joint services, supporting the CIN’s healthcare providers in care management, pharmacy management, patient engagement and other key areas. NS-EEH’s CIN includes more than 3,000 system-employed physicians, affiliated physicians and advanced practice providers, and nine hospitals across Chicagoland.

In collaboration with Lumeris, the organizations will manage joint risk arrangements, leveraging AI as a central component of their technology and approach. Lumeris stands out as the only value-based care enablement company with experience working across various patient populations, including those covered by Medicare Advantage, CMMI programs, commercial insurance, and Medicaid. This partnership aims to enhance collaboration among patients, physicians, and care teams, ultimately leading to improved clinical outcomes, a better experience for both patients and providers, and more efficient management of healthcare costs.

Formation of New ACO Models

Furthermore, NS-EEH and Lumeris will work together to address healthcare disparities in underserved communities by establishing new models of care under the accountable care organization (ACO) framework. Initially, NS-EEH and Lumeris will focus on the opportunity to participate in the Centers for Medicare & Medicaid Services’ (CMS) ACO Realizing Equity, Access, and Community Health (ACO REACH) model. This advanced value-based care model seeks to streamline care coordination and improve health outcomes for traditional Medicare patients. In the future, the partner organizations will expand their focus to include other types of accountable care and population health models to serve our diverse communities.

Given Artificial Intelligence’s potential to improve patient care and reduce costs, it’s no surprise that AI applications are gaining momentum in health care. As your organization explores the benefits of AI in your journey towards Value-Based Care, however, you need to carefully assess the implications, for better and worse.

Evaluating AI implications can be tricky. Healthcare AI varies widely, with clinical technology paving the way for advancements in diagnostics and treatment. But pressure on ACOs to achieve savings is spurring consideration of machine assistants for customary clinician services. That’s the message of one recent study suggesting that AI chatbots may outperform physicians in communicating with patients, offering higher-quality responses and displaying greater empathy. The study evaluated how chatbots versus physicians responded to 195 patient questions from Reddit’s r/AskDocs. Surprisingly, healthcare professionals who reviewed the responses favored chatbot answers over those from physicians in terms of quality (78.5 to 22.1 percent) and empathy (45.1 to 4.6 percent). Not a great report card for physicians!

But before planning to use chatbots in patient education, navigation, and coaching – especially given staffing shortages in health care – ACOs should closely examine the underlying assumptions. Consider these very human factors: How do patients feel about discussing treatment plans with chatbots? Was the study validated and reviewed by peers?  What were the study’s limitations and biases? Did physicians couch their responses with caution due to liability or clinical concerns? Either could have negatively affected the tone of physician communications.

The rapid adoption of AI technology risks incorporating human biases into algorithms, perpetuating gender and race biases through AI healthcare recommendations. Before jumping on the AI bandwagon, we need a better understanding of the effects on physicians and patients, as well as a thorough evaluation of potential unintended consequences.

There may be an advantage in time and money to using chatbots to assist in patient education and to support—not replace–human roles in medicine. We still need to preserve essential conversations between patients and physicians to maintain trust. Ceding that direct communication to technology could erode the patient-physician relationship. It would also undermine efforts to recruit talent into the healthcare profession, where shortages of skilled clinicians is already a significant issue, especially in rural and poorer communities.

Under pressure to adapt to Risk, many ACO stakeholders may be eager to deploy AI solutions. To resist being swept up by the momentum, carefully consider your options, support your participating clinicians in their clinical AI applications, and explore how you might collaborate.

Here are three guidelines for leveraging AI to strengthen your organization while recognizing potential weaknesses of machine-based systems:

1. Use AI to analyze complex data for risk identification, patterns, and variations in healthcare services and costs. AI’s ability to efficiently analyze diverse datasets aligns well with Value-Based Care. Personalized treatment plans based on multiple patient data points can be developed using AI analysis. For instance, AI algorithms can drive episodes of care, enabling ACOs to compare procedure costs, reduce variations, target patients for clinical review, and identify opportunities for improvement. However, be sure to exercise caution and scrutinize algorithms for potential biases that may impact population groups and health equity.
   
2. Evaluate the use of AI in creating patient materials for review by clinicians. ACOs have a responsibility to provide patients with factual information, support medical decision-making, promote cost transparency, and engage patients and their families in the process. Chatbot-generated communications, subject to clinical review, can be an efficient way to develop the necessary tools.
3. Defer replacement of direct communications with patients with AI and test the programs first. Pilot AI-driven communication and education tools, such as patient check-ins and self-management programs, with evaluation of changes in outcomes and patient acceptance. The urgency to utilize data wisely will drive ACOs toward AI solutions. Remember that technology is never neutral. Plan carefully for human and non-human resources to ensure that any AI applications benefit your organization and avoid potential, significant harm.
   

About Theresa Hush

As CEO and Co-founder of Roji Health Intelligence, Theresa Hush is a healthcare strategist and change expert with experience across the health care spectrum, including public, non-profit and private sectors. Her accomplishments include leading the transformation of Blue Cross Blue Shield regulations in Illinois, improving access to care as Director of the Illinois Medicaid program, and serving in executive leadership for both private payers and physician organizations. An expert at creating consensus for desired change through education and collaboration, Terry helps organizations take actions that will direct their future through meaningful technology and programs.

Given Artificial Intelligence’s potential to improve patient care and reduce costs, it’s no surprise that AI applications are gaining momentum in health care. As your organization explores the benefits of AI in your journey towards Value-Based Care, however, you need to carefully assess the implications, for better and worse.

Evaluating AI implications can be tricky. Healthcare AI varies widely, with clinical technology paving the way for advancements in diagnostics and treatment. But pressure on ACOs to achieve savings is spurring consideration of machine assistants for customary clinician services. That’s the message of one recent study suggesting that AI chatbots may outperform physicians in communicating with patients, offering higher-quality responses and displaying greater empathy. The study evaluated how chatbots versus physicians responded to 195 patient questions from Reddit’s r/AskDocs. Surprisingly, healthcare professionals who reviewed the responses favored chatbot answers over those from physicians in terms of quality (78.5 to 22.1 percent) and empathy (45.1 to 4.6 percent). Not a great report card for physicians!

But before planning to use chatbots in patient education, navigation, and coaching – especially given staffing shortages in health care – ACOs should closely examine the underlying assumptions. Consider these very human factors: How do patients feel about discussing treatment plans with chatbots? Was the study validated and reviewed by peers?  What were the study’s limitations and biases? Did physicians couch their responses with caution due to liability or clinical concerns? Either could have negatively affected the tone of physician communications.

The rapid adoption of AI technology risks incorporating human biases into algorithms, perpetuating gender and race biases through AI healthcare recommendations. Before jumping on the AI bandwagon, we need a better understanding of the effects on physicians and patients, as well as a thorough evaluation of potential unintended consequences.

There may be an advantage in time and money to using chatbots to assist in patient education and to support—not replace–human roles in medicine. We still need to preserve essential conversations between patients and physicians to maintain trust. Ceding that direct communication to technology could erode the patient-physician relationship. It would also undermine efforts to recruit talent into the healthcare profession, where shortages of skilled clinicians is already a significant issue, especially in rural and poorer communities.

Under pressure to adapt to Risk, many ACO stakeholders may be eager to deploy AI solutions. To resist being swept up by the momentum, carefully consider your options, support your participating clinicians in their clinical AI applications, and explore how you might collaborate.

Here are three guidelines for leveraging AI to strengthen your organization while recognizing potential weaknesses of machine-based systems:

1. Use AI to analyze complex data for risk identification, patterns, and variations in healthcare services and costs. AI’s ability to efficiently analyze diverse datasets aligns well with Value-Based Care. Personalized treatment plans based on multiple patient data points can be developed using AI analysis. For instance, AI algorithms can drive episodes of care, enabling ACOs to compare procedure costs, reduce variations, target patients for clinical review, and identify opportunities for improvement. However, be sure to exercise caution and scrutinize algorithms for potential biases that may impact population groups and health equity.
   
2. Evaluate the use of AI in creating patient materials for review by clinicians. ACOs have a responsibility to provide patients with factual information, support medical decision-making, promote cost transparency, and engage patients and their families in the process. Chatbot-generated communications, subject to clinical review, can be an efficient way to develop the necessary tools.
3. Defer replacement of direct communications with patients with AI and test the programs first. Pilot AI-driven communication and education tools, such as patient check-ins and self-management programs, with evaluation of changes in outcomes and patient acceptance. The urgency to utilize data wisely will drive ACOs toward AI solutions. Remember that technology is never neutral. Plan carefully for human and non-human resources to ensure that any AI applications benefit your organization and avoid potential, significant harm.
   

About Theresa Hush

As CEO and Co-founder of Roji Health Intelligence, Theresa Hush is a healthcare strategist and change expert with experience across the healthcare spectrum, including public, non-profit and private sectors. Her accomplishments include leading the transformation of Blue Cross Blue Shield regulations in Illinois, improving access to care as Director of the Illinois Medicaid program, and serving in executive leadership for both private payers and physician organizations. An expert at creating consensus for desired change through education and collaboration, Terry helps organizations take actions that will direct their future through meaningful technology and programs.

The VBC delivery model encompasses various approaches with the most common being Accountable Care Organisations (ACOs) and Integrated Delivery Networks (IDNs) in the US and  Integrated Care Systems (ICS) in the UK.  Both countries’ approaches are networks of healthcare providers (hospitals and physicians) who work together to deliver high-quality coordinated care to beneficiaries while controlling costs.  The benefits of VBC models include better patient health outcomes at a lower cost, streamline delivery via coordinated care teams, focused preventative care and treatment plans for patients, less physician burnout, lower costs for payers, and a healthier patient population due to better adherence to treatment.  

While there are many benefits to VBC, there are also some significant obstacles that must be overcome for this type of healthcare delivery model to be a success.  This includes dealing with disparate IT and health records systems, outdated workflows, and lack of internal resources which is a consequence of patients seeing multiple physicians, specialists, etc. who are using different data handling platforms throughout the course of treatment.

When it comes to VBC IT solutions, there are six tools that are essential for tracking, monitoring, and measuring patient outcomes.  These include IT tools to identify patient cohorts, segment patients by risk, aid clinical decision-making, manage care coordination, carry out patient activation, and finally, measure performance and report outcomes.  

Over the years, Signify Research has had the opportunity to speak to 100s of VBC decision-makers and buyers from ACOs and IDNs in the US and similar organizations internationally about their healthcare IT needs.  Our conversations with these organizations have provided greater insights into the current drawbacks of utilizing these technologies as well as what needs to change to improve these IT tools for the better. 

Tools to Identify Patient Cohorts

Our research has highlighted that electronic health record (EHR) systems are the main sources of patient information that are used to identify specific patient cohorts to target as part of VBC, coupled with manual data handling processes.  EHR systems can vary across providers’ settings, with some being more basic with limited clinical decision support (CDS) on offer including minimal highlighting of care gaps and no priority ranking of patients or insights on the financial impacts of closing these care gaps.  EHR systems that are more advanced tend to provide modules that have robust CDS that highlight actions to prioritize patients and provide some input on the cost impact of closing care gaps.  

However, gathering this information to identify patient cohorts to target for VBC is not always a straightforward process.  A majority of ACOs and IDNs that leverage EHR systems to identify patients use a mixture of DIY business intelligence tools such as Tableau, PowerBI, and Excel, for example, combined with some form of a dedicated commercial health insights solution drawing on EHR data.  This process is not straightforward and involves interrogating multiple data sources in various locations to develop a fuller patient view that includes manually pulling data from EHRs/Data Warehouses, claims portals (US-only), self-developed DIY tools, and social determinants of health (SDoH) tools.  Having to pull in data from multiple sources manually does not always display in a way that can help these organizations clinically, especially when some of the data is insignificant or inaccurate.    

When identifying patients to target for VBC, key things that care management teams look at include frequency of hospital admissions/readmissions, frequency of ED visits, type and number of chronic conditions, social needs data, medication spending, and screening tests.  As VBC organizations continue to grow and mature, the demand for more data points beyond EHRs is becoming increasingly important to help accurately identify patients to close care gaps.  With this comes growing interest in the need for sophisticated IT tools that automate processes and improve current workflows. 

Tools to Risk Stratify Patient Cohorts

The VBC providers we have spoken to have highlighted a reliance on several off-the-shelf algorithms that are used to segment patient cohorts identified from EHRs into high-risk/low-risk categories as a way of prioritizing who needs immediate interventions and care plans.  The algorithms in use include, for example, Milliman RX, Hierarchical Condition Category (HCC), Charlson Comorbidity Index, QAdmission Risk Algorithm (UK), Electronic Frailty Index (UK), and Kaiser Triangle.

The reliance on these algorithms once again requires care management teams to utilize manual data handling processes that include a mix of self-developed business intelligence tools combined with some health insights software.  As risk stratification is an important part of VBC, most organizations are currently not using sophisticated tools for various reasons related to issues of cost and lack of internal resources.  But the interest and need are there to look at IT tools that can improve workflows and help to focus on high-risk, high-cost patients in a more efficient and less laborious manner.

Clinical Decision Support Tools

Across VBC organizations we have engaged with, there is a wide variety of CDS software tools in use depending on where the ACO, IDN or other organization is based on their IT set-up journey.  Some have minimal or no CDS tools for closing gaps in care and rely entirely on manual processes to find and prioritize patients for care plans.  Other organizations have CDS support in the form of limited actionability that provides some software assistance with identifying cohorts but still requires manual work to input/extract relevant patient data.  The most advanced VBC organizations have developed integrated tools/dashboards that are combined with cohort identification and risk stratification IT tools and CDS modules providing care gap closure recommendations. 

While advanced CDS setup is what most organizations aspire to, the system is still not perfected as many CDS options are not integrated with care coordination team workflows requiring timely manual processes and additional staff resources.  There is a growing demand for the use of mature, integrated tools that mirror the VBC journey and bundle cohort identification, risk stratification, and CDS in health insights into one seamless end-to-end workflow.  

Population Health Management Tools

Another health IT needs includes improvements to current population health management (PHM) tools on the market.  Many organizations currently use broader dedicated PHM tools that enable care management teams to view cohorts based on risk and then drill down into specific patients to receive input and advice on what actions are needed to close gaps in care.  This specialized software allows for data visualization of common actions across cohorts that would lead to the greatest impact from a financial and clinical perspective.  

While dedicated PHM software is mostly used in medium to large-scale VBC organizations, many of the buyers we have spoken to have highlighted the dissatisfaction that cohort ID is mostly from siloed data sources that are not always accurate or up to date which increases the potential for patients to be incorrectly prioritized.  Also, many of the tools are not as user-friendly and require dedicated support from the IT/informatics team to manipulate data.  The demand is for solutions that not only provide a holistic patient view but also can be easily manipulated by care management teams without having to rely on technical or informatics expertise.  

Patient Activation and Outreach Tools

Our conversations with VBC decision-makers and buyers have also illustrated that despite the demand and use of IT tools for PHM, the telephone remains the primary method of contacting patients and enrolling them into VBC.  Enrollment success varies greatly across organizations, with some leveraging additional outreach tools such as texting tools and various patient apps and portals to contact patients.  

Patient communication is initiated and managed via workflows that once again originate from the EHR which houses patient contact information.  Organizations that have smaller, less diverse populations and those who have either invested in specific PHM IT tools to manage the process or who have developed their own in-house IT tend to experience higher patient enrollment in VBC.

However, while not high on the IT improvement wish list, many VBC buyers have expressed a desire to access outreach tools that better integrate with other care coordination workflows to streamline and expedite patient outreach activities and generate engagement.  

Reporting and Performance Tracking Tools 

To judge the eligibility of ACOs and IDNs for reimbursement payments and shared cost-savings, these organizations are required to participate in annual audits that measure performance and track outcomes.  Analyzing data for these audits is extremely valuable, but it tends to be a labor-intensive process and many healthcare organizations lack adequate resources and skill sets to create these reports.

Currently, most organizations use some form of DIY BI tools created by internal staff to track various program success metrics and KPIs around strategy, operational, and process improvements.  Most medium-to-large scale organizations rely on internal data analytics/informatics teams to develop IT tools via Tableau, Excel, Qlik that provide details on specific performance measures. 

This method of reporting again requires an abundance of manual tracking/reporting activities with automated tools used less commonly.  And this reliance on specific data analyst teams creates a backlog of reporting which makes it impossible to monitor performance in real time so strategies can be implemented to correct or improve outcomes before year-end.   

What PHM solutions are truly needed?

In summary, the six types of health insights IT tools that are essential for VBC organizations are not without significant drawbacks.  What is clearly not working is the lack of a holistic 360-degree patient view, and data limitations in terms of latency and access with multiple data feeds leading to missing and outdated patient information.  With the variety of vendor PHM IT tools in use that are falling short and still need to rely on manual processes, there are growing challenges in creating clear, coordinated workflows that share information back and forth between care management teams and frontline providers.  

Our conversations with VBC healthcare leaders have illuminated three key purchase drivers for any PHM IT tool which includes examining how these tools improve patient care, improve clinical staff workflow/efficiency, and reduce data fragmentation/data siloes.  What is needed for VBC are IT tools that ensure actions recommended by dedicated care management teams are visible and front-facing for providers to act upon as they interact with patients.   Also, having real-time data feeds and tools to inform care management would be extremely beneficial to VBC organizations in terms of monitoring and improving healthcare outcomes.

About Rohinee Lal 

Rohinee Lal is the Principal Analyst at Signify Research, a research advisory company providing healthtech marketing intelligence powered by data. Rohinee joined Signify Research’s Custom Research & Consultancy team in early 2022. She brings over 24 years of experience collecting, analyzing, & presenting market intelligence across various industries including pharmaceuticals, medical devices & digital health.

What You Should Know:

– Aledade is continuing its strong momentum today, announcing that Cigna Healthcare Medicare Advantage customers can now receive value-based care from Aledade’s network of independent primary care practices.

– Participating practices can access Aledade’s cutting-edge data analytics, user-friendly guided workflows, and health care policy expertise, as well as integrated care services supported by AledadeCare Solutions.

– This news comes shortly after Aledade announced a 10-year collaboration with Humana, and a partnership with CareFirst Blue Cross and Blue Shield to advance value-based care to more independent physicians. 

What You Should Know:

– Lumeris is launching Tribus, a value-based care accelerator for practices to convert from fee-for-service to value-based care using a community based-model.

– Under the direction of Dr. Chuck Willey, CEO of Tribus, who is a practicing internal medical physician in St. Louis, doctors will participate in physician-to-physician training and mentorship for anyone looking for a better way to deliver at-risk care for senior populations.

Why It Matters

The Medicare population is projected to be nearly a quarter of the U.S. population in the next ten years. With health systems influencing the vast majority of expenditures for healthcare delivery in the United States, Tribus supports coordinating the experience of care across all venues of delivery. This is accomplished in a shared risk partnership structure where Lumeris is aligned around driving performance outcomes with the participating physician partners.

“It’s an accelerated, community-based approach for practices to convert from fee-for-service to value-based care by learning directly from doctors who have operated in this model for decades,” said John Fryer, President of Tribus and SVP of National Markets at Lumeris. “For practices that want to convert to total cost of care arrangements and are ready to make the leap, this is hand-to-hand work that drives quality patient outcomes, satisfied consumers and solid financials for physicians, payer partners and ultimately patients.”

What You Should Know:

– Providers believe 96% of payment is now value-based in some capacity, and 58% believe their EHR vendor won’t be able to support the data strategies required to thrive under value-based care, according to a new study conducted by Morning Consult and Innovaccer.

– The 37-page national research study uncovers key IT infrastructure issues healthcare leaders said are impeding or essential for progress towards accelerating their transformation to value-based care.

The State and Science of Value Based Care

Only 4% of providers today report using pure FFS with no links to quality and value, and that plummets to 1% by 2025. Providers believe the payment model that’s historically dominated in healthcare has flamed out, and that 96% of healthcare payment today has connections to care quality, cost reductions and, in some cases, patient experience. That leaps to 99% by 2025.

Moreover, while providers report they have moved 96% of their revenue into some form of performance risk, 80% of those programs operate on a FFS architecture, where claims submission (as opposed to population-based payment) remains the driving force for value-based analysis and payment. The FFS architecture is even present in Shared Savings models, according to respondents, where healthcare costs are compared with a goal, and providers and payers share in the savings or losses.

– 58% said they didn’t believe their EHR vendor could support their enterprise data strategy.

– 42% said their data is highly fragmented and siloed, a blind spot for insights, workflows, actions, and reporting essential for value-based care delivery.

– 48% said they’re not confident their organization has the infrastructure to capture and use the full range of patient data.

– 41% said their organization needs population health analytics to advance their enterprise data/information strategy, making it the #1 capability sought among ten priorities offered.

– 68% said their organization doesn’t have the AI capabilities to drive digital transformation essential for value-based care.

– 69% of healthcare leaders said they aren’t using technology to identify at-risk patients.

– Despite a 94% increase in the number of executives who expect consumer-generated data to have a high impact on SDoH by 2025, 72% of respondents aren’t integrating medical and social determinants data.

In addition to presenting key findings on providers’ outlook on value-based care, the State and Science of Value-Based Care report covers value-based care challenges and opportunities reported by respondents; addresses the people, process, and technology gaps respondents said must be bridged; and provides expert commentary and guidance to help providers to put their data to work to accelerate their transition to value.

“The research shows a strong relationship between an organization’s investment in modern digital infrastructure and their ability to succeed with value-based payment models,” Stevens said. “Digital investments will be the deciding factor for more mature risk-bearing organizations. The key to value-based care is the ability to integrate data from EHRs and other IT silos—clinical, claims, labs, pharmacy, telehealth, remote monitoring, social determinants, consumer-generated, you name it—into a unified patient record that lets providers drive the analytics-driven workflows, care management, risk stratification, and patient engagement strategies to drive better outcomes at a lower cost.”

For more information, download the State and Science of Value-Based Care

For the better part of a decade, the shift toward value-based care in the U.S. has been driven by the establishment of the Center for Medicare and Medicaid Innovation (CMMI). Working to develop, test and evaluate new payment and delivery models in Medicare, Medicaid and the Children’s Health Insurance Program, CMMI has taken aim at improving the provider experience, generating better patient outcomes and reducing the overall cost of care.

Recently, CMMI stated that by 2030 every Medicare beneficiary should be in a value-based relationship – either an ACO or ACO-like model or Medicare Advantage – with a significant emphasis on health equity. 

Historically, CMS models have focused on enabling providers to increase accountability for patients’ health through ACO condition-specific models and payer-supported models like Medicare Advantage. However, with approximately 13 active models, CMS has been consolidating and simplifying their models, resulting in fewer disease-specific models and a focus on making provider and patient enrollment easier. 

To succeed across the spectrum of risk, especially as provider enterprises assume more risk and accountability for holistic patient care, they must invest in the right infrastructure that delivers differentiated patient and provider experiences, while producing better clinical, financial and operational outcomes. For this to happen, provider enterprises must focus on the following key strategies:

1. A primary care-led delivery model with enhanced virtual care and clinician access, supported by high-risk clinics. In this model, primary care physicians are supported by a robust infrastructure and given tools to focus on their overall panel, while the patients requiring the most attention are provided with focused support by high-risk clinics. With aligned incentives, primary care physicians can keep expanding their managed care panels, thereby reducing access issues, while thriving in value-based contracts. 

2. Robust medical management infrastructure to meet patient needs for specialty, acute, facility, home and post-acute care needs. This approach brings specialists and facilities in with the right capitation models and incentivizes them to improve care outcomes while optimizing utilization. 

3. Differentiated patient experience to improve satisfaction, clinical outcomes and loyalty. Ensuring that patients can navigate the complex healthcare system with the right blend of technology and staff increases the likelihood of the best outcomes for patients. To do so, care teams and primary care physicians should focus on ensuring patients have the most possible choices, potentially through on-demand access. 

4. Leveraging data and analytics. While there are an increasing number of data sources, the lack of interoperability and data silos still make it difficult to build the full picture of a patient’s health and overall well-being (including SDoH), which sub-optimizes outcomes. Investing in solutions that enable the unification of all data into a single platform, drawing correlations and proactively identifying at-risk and emerging-risk patients at each step of the journey is invaluable in intervening at the right time. 

5. Designing programs and infrastructure with health equity in mind. The need to drive improved health in our communities is critical and is being propelled by CMS’ 2030 objective. Moving forward, organizations will have to build infrastructure that can collect health equity data, report on it and service all Medicare beneficiaries. Without timely investments now, practice operations, reimbursement and ultimately patient care will fall behind.

6. Building a cost-efficient and scalable infrastructure. To succeed in the ever-evolving and dynamic reimbursement environment, provider enterprises need to figure out the best way to structure their care delivery operations and focus on their core strengths, while mission-supportive chores are delegated to effectively create a scalable, asset-light infrastructure that adapts to their changing needs. 

The underlying theme across all these efforts is an acceleration toward value-based payment models that focus on driving more accountability for providers and improving health outcomes for patients. Provider organizations must be cognizant of the 2030 goals as they build patient-centric and physician-led models that help them succeed across the spectrum of risk. 

About Siddharth Thakkar 

Siddharth Thakkar is Vice President, Product and Marketing at IKS Health, a scalable, proven, cloud-based physician enablement platform that enables provider enterprises to deliver better, safer and more efficient care through a strategic blend of technology and expertise.