As the healthcare landscape shifts toward population health and value-based care, including alternative payment models, it is apparent that the payers in our country hold much of the data needed to be successful in the new world of healthcare. They also often set the metrics and even perform care management. But are they the best source of truth to drive the collaborative, preventative strategies needed to succeed?
The “data divide” between payers and providers will likely shrink during this shift from fee-for-service to value-based care, where population health and care coordination take center stage. This new landscape equally increases both the need for data and the dependence on payers and the data they possess. Yet, clinical decision-making necessitates more than claims that are gathered once or twice monthly. Providers should be able to draw on real-time institutional data, evidence-based medicine guidelines and other key sources in one platform to create individualized care plans for patients.
If providers aren’t part of a larger health system that invests in data warehousing, mining and analytics, they can be at the mercy of payers – both in terms of the data needed to drill down into their population and the metrics that the payer determines are valuable to demonstrate quality care. In its 2016 Quality Strategy report, The Centers for Medicare & Medicaid Services underscored the importance of a robust data infrastructure, calling it, “necessary to ensure transparency of accurate quality and cost information.”1 Providers can be between a rock and a hard place – and payers know it.
If payers hold many of the cards, providers must rely on their data to drive the focus on how to direct and measure care. In addition to lacking real-time, comprehensive data, payers also focus on specific details – such as the metrics needed to hit certain goals, including precise measurements like A1C levels – to determine care plans, reimbursement or incentives. Population health implores us to move beyond this framework and to appreciate that human beings – and medicine – are far more complex than any singular set of metrics.
Moving Beyond the Payer-Provider Strain
Now let’s widen the lens for population health. The payer-provider strain can be amplified as many payers aren’t tackling the socio-economic determinants of health or integrating behavioral health into the traditional set of clinical metrics. Approaching care delivery through disease-specific metrics, as opposed to a holistic approach that incorporates all aspects which influence health, causes fragmentation and attenuated gains.
How do providers begin to take back control? By knowing your population in detail and investing in systems that aggregate critical clinical, social, financial and population-level data that helps provide preventive and targeted measures for successful health outcomes.
The goal of moving from the payer-claims approach to a more holistic approach, which views the historic and future needs of the population you serve, reinforces the positive impact of strategic care coordination that integrates more than medical services.
Create a Quantifiable Approach
When you have the right data, at the right time – and the expertise both to analyze and operationalize that data into positive change – you can develop processes that show your clinical and operational approach achieves meaningful outcomes while potentially lowering costs. The ability not only to hit certain metrics, but also to track overall success in your population is a significant differentiator.
Build the business case for your approach by creating the processes that use your network or community expertise and resources to achieve meaningful change for the emerging risk within your population. Want to achieve true change? Go beyond disease or case management to create the framework using evidence-based medicine guidelines in conjunction with your knowledge of the broader needs of your population. By quantifying the value of your approach, you can negotiate payer contracts that include increased reimbursement or enhanced incentives with the right metrics. Instead of passively receiving “x” dollars for each episode of care, build a business case that leads to “x + n” dollars for the outcomes of a holistic, team-based approach to care delivery.
The path to putting providers – and medicine – back in the driver’s seat includes a number of stops along the way. Chief among them: obtaining multi-source historical and real-time data regarding a population; using the right community resources and continuum partners to support care delivery; creating a holistic care coordination approach; and building a business case that reveals the success achieved by going beyond the metrics. If you execute this strategy well, you’ll not only show that care coordination directly impacts the well-being of each and every patient, but you’ll also expose the flaws of payers holding all the power in care delivery.
Read other articles in this care coordination series:
5 Considerations for Successful Care Coordination and Population Health
Mitigating the Impact of Social Determinants on the Success of Clinical Care
Technology-Driven Workflows Are Hallmarks of Optimal Care Coordination
- The Centers for Medicare & Medicaid Services. CMS Quality Strategy 2016, p. 6. November 2015.