As we move toward value-based care (VBC), provider contracts are posing challenges for health plans and providers. When I previously served as vice president of quality at a large health insurance company, I was part of a team that reviewed provider contracts that included quality risks. Adding my role to the review process has helped us identify reporting requirements that cannot be met by the health plan and align them with action priorities, reducing frustration for our network and quality teams. Ta.
Value-based contracting is rapidly evolving, and federal and state regulatory agencies are imposing new mandates. The Centers for Medicare and Medicaid Services (CMS) plans to transition traditional Medicare and many Medicaid beneficiaries to VBC arrangements by 2030. An increased emphasis on quality is further driving demand for VBC contracts as payers seek them out and providers recognize their importance in increasing volume. And income.
This acceleration to VBC results in complex contracts that require complex data management to achieve high-quality outcomes. Here’s how quality considerations and related data affect his VBC contract.
Understand VBC contract concepts
Most contracts are categorized into different types, increasing in complexity as risk sharing increases. Below are the most common contract concepts, from minimal risk sharing to more comprehensive risk sharing.
- Gain sharing: For providers just starting out with VBC, you get an upside-only arrangement as you share the savings rather than the risk of loss.
- Up/down risk model: Providers share both savings and risks. In these contracts, the provider receives an allocation of funds on a per-patient basis and retains a defined portion of any surplus generated. However, if you spend more than your quota, you will be responsible for a designated portion of the deficit.
- Lump sum payment: Healthcare providers receive a fixed payment for all services within a single care or a specific time period, such as joint replacement surgery. If your healthcare provider provides the right care and prevents complications and errors, some of the money saved stays with you. However, if the cost exceeds a certain amount, you will be responsible for the deficit.
- Capitation – Risk for experts only: Payers typically establish risk pools based on monthly payments per member (PMPM). The amount payers give providers is based on, among other things, expected average healthcare utilization and the risk profile of the patient pool. The Provider is solely responsible for the professional risk.
- Capitation – Global Risk: This arrangement is the same as the professional-only risk described above, except that the provider and payer fully share the risk in these agreements.
As each party takes on more financial risk, the need for VBC expertise and technology to support care and contract management increases. There are several contractual considerations that can help payers and providers build the right foundation for a successful her VBC.
Identify the best approach for all parties.
While it may be unlikely to achieve a perfect deal for all parties, better collaboration is more likely to result in a win-win scenario. Initial negotiations often begin with a health plan template tailored to your goals, but health care is diverse. Healthcare providers and payers need to ensure that appropriate stakeholders are involved to ensure quality metrics tailored to the provider’s specific patient populations, such as children and patients with diabetes. there is. Payers and providers can also align with standards such as NCQA and CMS Core Set to help parties determine the most appropriate level of risk sharing, ensure measures are reportable, and collect necessary data. You also need to do so.
Consider measures tailored to each member
Multi-segment planning should consider measures that best reflect each group’s desired outcomes and look for commonalities wherever possible. Another consideration is that payers need to consider experts when negotiating with health care providers. If you have an endocrinologist in your practice, having quality diabetes-related measures in your contract will benefit all parties.
Focus on the carrot, not the stick.
Good contracts encourage compliance through incentives rather than penalties. Payers should link provider incentives to defined quality measures and promote ease of reporting, such as CPT 2 codes and providing supplemental data to health plans to lower data acquisition costs. This approach, highlighted by Apex Health’s Jessica Columbus, drives efficiency for healthcare providers, including using point-of-care alerts to guide actions that align with contract goals.
Manage everything with one data feed
An ongoing challenge for VBC is building the necessary infrastructure and technology. Complicating the issue, different health plans have different specifications for their supplemental data files, necessitating a standardized minimum data set. Even with standardized measures, integrating data from multiple sources is extremely difficult. Efficient use of available data is important for healthcare planning to avoid frequent revisits to healthcare providers.
Consider the impact on data aggregation. Suppose a provider works with her seven plans, each with separate gap-in care lists and inconsistent header data. Payers will then need to invest resources in integrating this data to effectively manage quality standards.
Nick D’Ambra, former Vice President of Quality Improvement at AbsoluteCare, shared his key experiences at the RISE HEDIS & Quality Improvement Summit. A central question arose while working on a state-mandated performance improvement project to streamline clinical practice guidelines. Could there be a broader opportunity to collaborate with other managed care organizations to create a uniform file format that meets all of their needs?
Bridging the data management gap
Collecting and reporting value-based care (VBC) data is challenging, especially as the amount of data increases as VBC becomes more common. However, the impact of AI technologies such as machine learning, natural language processing, and optical character recognition, including generative AI such as ChatGPT and Bing Chat, is significant. These technologies excel at aggregating and synthesizing patient data from various sources.
Unlike spreadsheets that require manual entry and manipulation, health plans can automate AI to drive data ingestion and tasks, identify patterns, highlight relevant information, and streamline processes. Leveraging data both prospectively and retrospectively is critical for payers and providers managing quality standards in contracts, and AI enables this at scale.
Winner at VBC
Organizations that effectively leverage AI to accurately identify, monitor, and report quality outcomes will be successful in winning value-based contracts, thereby enhancing patient health and strengthening financial performance. I can.
About Elissa Toder (MBA)
Elissa Toder, MBA, is Vice President of Quality Improvement Strategy and Solutions at Reveleer. Elissa earned her bachelor’s degree in Health Policy Management from Penn State University and her MBA from Clark University.
