Health Plan Data Governance Assists Value-Based Reimbursement

March 30, 2018 - Health plan data governance plays a key role in overcoming barriers related to industry-wide adoption of value-based reimbursement, according to a two-year study conducted by CAQH CORE.

 Health plans are industry leaders who should take an active role in addressing value-based reimbursement issues because health plans have expertise in managing complicated data.

Health plans can contribute to industry-wide adoption of value-based reimbursement by addressing data quality, data uniformity, and patient attribution concerns.

“Organizations across the country are experimenting with value-based payment models,” said CAQH CORE Director Erin Weber. “While innovation is needed, it is important that the industry find a common foundation for basic administrative operations.”

Payers and providers may lack processes or definitions to leverage their data assets for decision-making purposes. Managing data quality and standardization requires guidance from health plans, CAQH CORE asserts.

Health plans should endorse consistent use of existing medical and non-medical code set standards and initiate the process of promoting uniform data standards.

Plans can improve data quality by sharing and defining important data about beneficiaries’ social determinants of health (SDOH). SDOH data use is rapidly growing in the value-based care space to help reduce costs and improve care quality.

“Emphasis on SDOH is expanding, as this data is useful in programs to reduce inequities, improve health and reduce healthcare costs,” CAQH CORE said.

Health plans could help the industry with concerns related to patient matching, as well, the team suggested. Plans that standardized patient identifier data can improve care quality and population health beyond current industry capabilities.  

“As care is increasingly delivered in outpatient and other settings, patient identification today may simply be based on the name a person presents with at the time of a healthcare encounter, resulting in the inability to accurately aggregate all data for a given patient,” CAQH CORE said.

Attributing patients to providers in a value-based payment model is another critical challenge that health plans can tackle, CAQH CORE suggested.

“Healthcare providers participating in CAQH CORE research were quick to identify attribution as an important opportunity area for improvement in value-based payment operations,” the team said.

Health plans can address provider attribution challenges by using internal data to identify providers and the relationships between providers. Health plans could invest in additional transparency and clarity to help stakeholders understand how providers are attributed to patients.

“While it is essential for providers to understand attribution models when they engage in value-based payment arrangements, many indicated that they encounter barriers when trying to understand how patients are attributed to them.”

 Health plans should also catalog provider attribution models and develop a library of leading practices for efficient provider attribution. Catalogs help patients, as well as providers, understand how and why their provider is assigned to them.

“Patients need to understand why they may be assigned to see a given primary care provider (PCP),” the team said.

“If patients opt to choose a different PCP, there must be a process to change the attribution so that accurate cost and quality comparisons can be made in order to ensure a realistic picture of whether value-based payment is meeting its goals.”

CAQH CORE concluded by emphasizing that health plans, providers, government agencies, and related stakeholders need to become data collaborators to effectively implement value-based payments.

Health plans and other organizations that coordinate data sharing efforts are more likely to avoid administrative mistakes made in the fee-for-service payment landscape.

“Going forward, collaboration will become the currency of value-based payment,” the team said.

“As implementation progresses, for example, health plans and provider organizations are expected to become data and analytics partners. By collaborating to leverage their respective data strengths, these stakeholders can illuminate blind spots in care management and reveal richer insights about practice variation."