Clinical Data Analytics Key for Value-Based Care Reimbursement

December 08, 2016 - Many medical facilities have seen how the healthcare industry has been moving away from fee-for-service payment to value-based care reimbursement. Revere Health is one organization that jumped on the bandwagon early on and has quickly moved forward with improving quality outcomes and population health management.

“Healthcare is always a journey. Dealing in healthcare and its costs is an ongoing journey,” Beth Sant, Data Analyst at Revere Health, told HealthPayerIntelligence.com.

“Overall, Revere Health in around 2008 or 2009 really started looking at how that healthcare journey was changing and tried to move along in that process instead of sticking with fee-for-service because you could see that it wasn’t going to be sustainable forever. We’re an organization that really stays on top of changes and technology in healthcare. When we start seeing things move, we move with them instead of waiting for it to move us.”

About eight years ago, Revere Health began to move away from fee-for-service and slowly embrace value-based care reimbursement by incorporating quality care metrics and population health management, Sant explained.

“Around 2008, we really started looking at not just fee-for-service care but quality outcomes. We started with patient and care management,” Sant continued. “Our analytics and development team was on electronic medical records at the time but it was built for fee-for-service instead of built to work with quality measures and quality outcomes. Our analytics and development team built a tool that integrated into our EMR.”

Over time, the provider partnered with commercial payers like UnitedHealthcare and Blue Cross Blue Shield to create value-based care reimbursement contracts based on quality outcomes.

“We started small working on measures for certain diseases like diabetes, COPD, and congestive heart failure. We worked on quality measures such as lowering ENCs and making sure a patient is on a statin medication. We built analytical tools that took a look at our patients and found what diseases they had. It also looked at things they needed to get done,” she added. “Over the years, we started working with payers including Blue Cross Blue Shield and UnitedHealthcare. Then in 2012, we joined the Medicare Shared Savings Program to really start working on quality outcomes.”

The general move toward value-based care reimbursement rarely occurs without some obstacles among both payers and providers. Essentially, the transition from a more traditional fee-for-service payment system that providers have more experience in and jumping into a brand new payment platform has brought some complexities.

“Talking about challenges, it was definitely a challenge for providers to live in a fee-for-service environment. We always cared about patient outcomes but really started looking at some of those things little bits at a time,” Sant said. “We pick up certain pieces and don’t try to bite off the whole thing at one time. So that’s been successful for us - working on one or two improvements throughout the year and get those down to the workflow processes.”

The clinicians at Revere Health use multiple tools when managing patient care to improve the patient-doctor relationship and ensure the physician keeps track of a patient’s overall health.

“We have multiple tools we’re using such as the tool that we integrated into our EMR. Every patient that comes in for a face-to-face visit has a daily appointment report,” Sant explained. “It shows outstanding quality measures, chronic conditions they need to have assessed, emergency room or hospital utilization, and critical illnesses. The providers are using those tools while the patient is in the room to talk about metrics and different things they to take care of. They also try to get a feel for social issues or things that may impact their overall care.”

Data analytics technology and IT systems capable of interoperability are key for success in an accountable care organization. However, a survey from the McKesson Corporation found that 41 percent of payers claim interoperability problems and systems integration obstacles were some of their biggest issues in 2014. Some areas where ACOs could improve around these issues include gathering data that boosts care coordination, clinical decision-making, and chronic disease management.

Some of the key achievements from Revere Health transitioning to value-based care reimbursement and functioning as an accountable care organization include cost savings for its payers and patient base, improving clinical data exchange, and a general reduction in emergency room use and hospital admission rates.

“Using all of those tools, we’ve shown great improvement in quality outcomes over the years. Putting patients into these programs and using different tools has shown success such as better medication adherence,” she added. “We’ve had multiple successes with our quality piece over several years with both the Medicare Shared Savings Program and some of the other payers we participate with.”

“From a cost saving perspective, we’ve been focusing more on using health information exchanges to coordinate patient care better and help reduce ER utilization and hospital admissions,” Sant continued. “For the past two or three years, we’ve decreased our overall cost for our patients. We’ve been really working on our coding piece for diagnoses to show payers truly how sick patients are. Payers are establishing a threshold of what a patient should cost in a year so we’ve done some things to make sure that we’re accurately reflecting a patient’s true health and what their chronic conditions are.”

With fee-for-service becoming more and more incompatible with the payment structures of the healthcare industry, payers and providers will need to figure out how to adopt value-based care reimbursement. Sant’s advice is to start slow and to pick certain areas to work on.

“Don’t try to do it all at once,” she clarified. “Fee-for-service is going away and healthcare is definitely moving to a value-based care payment system. If you don’t believe that, then you will struggle in this process. You have to start off in pieces. If you’re not doing anything, then just pick certain things. For example, Revere Health started with with quality metrics among our disease-based patients like our diabetic and COPD patients.”

“We started working on a couple of quality measures for those patients. Every year, we’re adding some piece to the puzzle as part of value-based care,” she concluded. “You can’t bite it off all at once. It’s too much to take on. You have to take it a step at a time.”

Dig Deeper:

Key Steps for Payer Success in Accountable Care Organizations

How Payers Should Prepare for Value-Based Reimbursement