Value-Based Care News

Using Technology to Close Care Gaps, Improve Care Quality and Cost

Technology is able to identify and close care gaps and improve the cost and quality of benefits and services provide by payers.

Sponsored by Veradigm

- Research has shown that care gaps can be both harmful and costly when not properly managed. For example, not managing certain chronic diseases (e.g., diabetes) can lead to serious complications and escalating treatment costs. Resolving gaps in care is important to payers, providers, and the patients they serve. Doing so can positively influence patient health and lead to improvements in quality scores and reimbursement under risk-sharing arrangements such as Medicare.

For many years, industry experts have warned of the dangers of a healthcare system that is more reactive than proactive.

“Preventive care is underutilized, resulting in higher spending on complex, advanced diseases. Patients with chronic diseases such as hypertension, heart disease, and diabetes all too often do not receive proven and effective treatments such as drug therapies or self-management services to help them more effectively manage their conditions,” noted the authors of a Bipartisan Policy Center report published ten years ago.

Today, healthcare best practices firm the Advisory Board estimate that 18 percent of rising-risk patients — those with one or more chronic diseases whose symptoms are easily ignored — move into the most expensive cohort of patients, the high-risk population. According to the firm, care management efforts have proven effective in reducing rising-risk escalation rates by one-third. The key is alerting providers to essential risk factors of each individual patient.

Identifying and addressing gaps in care can have a significant impact on a payer’s quality metrics, and ultimately revenue. The Healthcare Effectiveness Data and Information Set (HEDIS) is one of the most widely used set of measures and includes a focus on care gaps. Risk adjustment measures — both those available through the Affordable Care Act and those in the Medicare Star Ratings System — stipulate certain eligibility requirements for identifying care gaps for patients based on age, gender, condition, and/or complications.

To help improve the quality of their plans, payers must work with providers and patients to ensure the latter receive appropriate care at the appropriate time.

Improving access to key data through technology

Healthcare has a well-documented interoperability problem. However, payers, providers, and vendors can work together with current technology to achieve data-driven results when they work as partners.

New and existing technology has the potential to change the way payers, and providers communicate, especially in sharing critical clinical data. Data is driving the most effective efforts by high-performing payers to improve patient care at a lower cost.

Access to relevant clinical data is critical to identifying and closing care gaps. The vast majority of providers have adopted EHR technology and have the data necessary to track patients and populations. But simply having the data isn’t enough. Data can be leveraged to identify patients at risk and technology can be used to support bi-directional information sharing between payers and providers at the point of care. This information exchange can fuel outreach efforts to reduce the number of non-compliant patients and correlating populations.

Examples of these exchanges include:

  • Payer-initiated alerts for preventive services or missed opportunities that require follow up by the provider
  • Provider ability to communicate back to payers on actions taken
  • Provider access to payer coverage approval requirements

Additionally, manual medical record reviews can be eliminated by automating data pulls from EHR systems using recognized standards. Applications and services built around the Fast Healthcare Interoperability Resources (FHIR) standards should lead the healthcare industry closer to semantic interoperability. Here and now, many of today’s EHR systems include standards for sharing data based on Consolidated-Clinical Document Architecture (C-CDA). Payers and providers can use C-CDA to facilitate information sharing.

Eliminating care gaps with open communication

Communication between stakeholders is key to closing and eliminating care gaps and improving quality measures. In many ways, healthcare’s lack of interoperability is part of a larger communication problem preventing these stakeholders from working together to improve the efficacy of care.

In addition to communication, documentation is critical. Yet many providers are unaware that lack of data captured and appropriately recorded in patient records can undermine quality improvement efforts. For example, providers need guidance to perform and document clinical activities that must be completed within a defined measurement window (e.g., child immunization status, mammograms).

Open lines of communication between providers, patients, and payers will allow important information to be captured and used to achieve cost-effective outcomes:

  • Providers are able to coordinate and align care across care settings
  • Patients and their caregivers have the knowledge and resources to manage their health
  • Payers can better engage providers and patients in prevention and wellness

EHR technology can facilitate the sharing of information at the point of care. Payers can educate providers about quality measurement and the data needed to satisfy specific measures. Providers can then identify and address areas for clinical documentation improvement (e.g., codes for screenings) to remove inefficiencies, delays, or failures in quality reporting. 

The data to close care gaps and improve care quality already exist. Having the right strategy and technical capabilities for making data actionable as close to the point of care as possible will determine the future success of health plans.

VeradigmTM – Transforming Health Insightfully

Veradigm is an integrated data systems and services company dedicated to simplifying healthcare with next-generation health insights and technologies.  Our solutions are designed to help increase efficiency, manage costs and improve outcomes for health plans and other healthcare stakeholders.  To learn more, visit www.veradigmhealth.com.