While stories about the ongoing impact of Covid-19 continue to flood national headlines, there is another rising trend in healthcare emerging in mainstream discussions: value-based care. For years, value-based care, a model that rewards better patient health outcomes, has been discussed as a lofty dream or an idealistic care model to bend the cost curve. Today, more than ever before, this “distant dream” is becoming a reality – largely due to recent implementation of interoperability rules.
In the last year alone, new interoperability mandates have accelerated value-based care adoption by improving data sharing across the healthcare continuum. For example, most recently the Centers for Medicaid and Medicare (CMS) began implementing the Interoperability and Patient Access final rule (CMS-9115-F), which mandates that payers and providers grant patients access to their health information. Additionally, under the Council for Affordable Quality Healthcare (CAQH) new interoperability rules, Committee on Operating Rules for Information Exchange (CORE) certified health plans will be required to make an updated value-based care patient roster available monthly to providers. The goal of these rulings is to smooth workflows, reduce unnecessary churn, and prevent data stagnation. With access to this timely information, provider encounter or claim information can move more accurately through health plan systems and provide real-time information with regard to value-based care contract performance.
The key to value-based care? Interoperability.
While many healthcare leaders appreciate the intentions behind these new rulings, many likely hear about these mandates and are immediately concerned about the resources that will be needed in order to comply. The good news is there are roadmaps in place to make implementation more seamless. In fact, CAQH has designed, developed, and approved new X12 EDI operating and infrastructure rules that will add this important information to routine eligibility transactions that pass between payers and providers every day. These new X12 EDI operating and infrastructure rules will provide the necessary information needed at the point of care to ensure value-based care attribution is recognized and quality measures are addressed efficiently.
Alongside CAQH, other industry groups are working to help organizations comply with these rulings by driving interoperability standards that support the adoption of value-based care models. Workgroups across the healthcare industry are focused on payment models with the goal of improving the efficiency of health data exchanges through education and advocacy across both payers and providers. Other groups and private sector initiatives are also helping to define industry best practices to implement consumer-directed data exchange.
Value-based care in action
With the rulings in place and innovative groups helping payer and provider organizations with implementation, value-based care is becoming a reality and improving patient outcomes. As an example, one leading organization took the initiative early on to design a new program to transition reimbursement away from fee-for-service and towards value-based care. The program rewarded Long-Term Services and Supports (LTSS) facilities and nursing facilities for high-quality and efficient treatment of enhanced respiratory medical conditions. The organization implemented both a quality framework based on efficient data exchange and a tiered value-based care payment strategy to reward its best providers on performance and quality.
Because of these early efforts to implement a value-based care strategy, this organization was better prepared to face the Covid-19 outbreak. Higher-scoring/tiered facilities were naturally better equipped to respond to the increased pressure, as well as scrutiny, on nursing homes that, tragically, affected those facilities, significantly. Also, this program allowed near real-time data visibility into each facility, including the number of advanced facility technology deployed, certified respiratory staffing and training levels, respiratory ventilator weaning rates, availability of services for high acuity ventilator dependent individuals and hospitalization rates – all critical data points when evaluating how to allocate resources.
We’re at an important crossroads in healthcare. Interoperability has risen to the forefront, empowering providers and payers with the information they need to implement value-based care models. Moving forward, the key will be ensuring that organizations have the right technology to quickly adjust to any future CMS interoperability ruling and continue the quality outcomes movement to value-based care.
Photo: LeoWolfert, Getty Images
