Pulling in the same direction: Collaboration is key for achieving value-based payment success

During the last decade, value-based care models have gradually become more prevalent. A recent federal report found that healthcare payments associated with alternative payment models (APMs) reached 34% in 2017, an 11% increase from 2015.¹ But embracing the shift from fee-for-service to value-based payment comes with many challenges, particularly when attempting to establish uniform operational processes to streamline implementation.

In 2005, the Council for Affordable Quality Healthcare (CAQH), a non-profit alliance of health plans and trade associations, established the Committee on Operating Rules for Information Exchange (CORE) to adopt and institute operating rules for administrative transactions in the U.S. healthcare industry. One of CAQH CORE’s primary functions was to standardize HIPAA electronic transactions. In 2012, this led to the HHS designating the organization as the authoring body for mandatory operating rules under the Affordable Care Act (ACA).

As Erin Richter Weber, director, CAQH CORE, Washington, D.C., said at MGMA19 | The Operations Conference, in April, it’s imperative that the healthcare industry comes together to promote uniformity, which CAQH CORE took the lead on for standardizing HIPAA electronic transactions.

Workarounds without standards often create operational inefficiencies, Richter Weber noted, “and if we keep doing that, we’re going to slow the progress of value-based payments and the value that they provide to our patients. Common rules for this information exchange are going to be really critical.”

Challenges presented by non-uniformity  

In CAQH CORE’s report All together now: Applying the lessons of fee-for-service to streamline adoption of value-based payments, many of the more than 130 healthcare organizations surveyed reported that the biggest impediment to implementing value-based payment models is non-uniformity.

For those surveyed, standardization was extremely important in several operational areas. In its absence, early adopters modified existing systems and created new ones. However, they don’t circumvent the challenges that have come about due to a lack of standardization, which include:

• Varied terminology: Terms associated with value-based care — such as “bundled care,” “cost of care,” “emergency department visit” and “primary care physician” — are interpreted differently by stakeholders, which may warrant standardization or new uses of data elements.
• Lack of a standard system: Data exchange is difficult because the current claims system was developed for fee-for-service reimbursement. In addition, EHRs were not designed to integrate clinical and financial data or act as analytics tools. There are also interoperability issues, which, for providers, have necessitated the creation of distinct data warehouses and custom reports for clinical data. Finally, payers have siloed systems, which makes it difficult to integrate and retrieve clinical data. 
• Diverse provider attribution and patient risk stratification models: For providers, the absence of transparency and uniformity among payer models can make their jobs more difficult and delay information exchange.
• Quality measurement programs difficult to utilize: For providers, the task of gathering clinical data and assembling reports is often disjointed, duplicative and ineffectual, which places undue burden on them.

 
In assessing these challenges, many practices, payers and vendors aren’t fully prepared operationally to support value-based payments. Consequently, CAQH CORE has been tasked with educating the healthcare industry on ways to streamline value-based payment.

“The ultimate vision of the work and what was agreed upon by the participants was that our goal is to develop a common infrastructure that drives the adoption of value-based payment models by reducing administrative burden and improving information exchange and enhancing transparency in the industry,” Richter Weber said about CAQH CORE spearheading the educational effort. “Thinking about what data is needed, how that data can be exchanged and when that data is needed.”

Opportunities to streamline value-based payment

In conducting research for the report, CAQH CORE identified five opportunity areas to serve as a baseline for best practices in consolidating processes and promoting dialogue between stakeholders to help remove operational barriers to value-based payments.   

Data quality and uniformity

Beyond the lack of standardization with respect to terminology, there is also an issue with terms used to classify date and time of an event, such as “discharge from an emergency department.” According to Richter Weber, “there’s an opportunity for the industry to pursue some voluntary agreement on definitions.”

Furthermore, data is often inaccurate, incomplete and/or not delivered in a timely fashion. As Richter Weber related, some of the biggest issues are with provider identity: “What is a provider location? Is it where they practice? Is it where they’re paid? That kind of information is doubly important when you’re looking into value-based payments and managing populations.”

The study also discovered that some requirements were not being enforced, such as use of the National Provider Identifier (NPI), which is compulsory with all HIPAA-mandated transactions. Other issues such as non-standard use of medical code sets and data embedded in notes in the EHR or in paper documents are often overlooked because of the effort it takes to extricate it.

CAQH CORE recommends:

1. Promoting and enforcing data standards that further value-based payment execution, particularly where federally mandated.
2. Pursuing voluntary agreement of standard definitions and ancillary data components in HIPAA-mandated transactions.

Interoperability

Exchanging and being able to use information is an ongoing issue in healthcare, particularly when stakeholders have common expectations. Richter Weber pointed to two types of interoperability that are key in value-based payments: technical interoperability and process interoperability.

“The standards and the technologies are mostly available,” Richter Weber said, pointing to guidelines brought forth by the Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC). “It’s just determining how the industry is going to use them, and how we can all get on the same page about using the same ones.”

As for process interoperability, Richter Weber insisted that workflows and expectations for exchanging information need to be established. “When should you expect to get information on patient attribution? Could that be common across all the plans a provider is working with?,” Richter Weber asked.

In addition, interoperability can help improve communication, which can lead to more engaged patients who are better able to help make decisions regarding their health.

CAQH CORE recommends:

1. Supporting the use of existing and emerging standards and technologies to foster technical interoperability.
2. Documenting value-based payment best practices by encouraging process interoperability.

Patient risk stratification  

Measuring risk assessment is a priority in value-based care. Multiple factors can affect population health over time, including patient age and financial circumstances. Providers and payers use this information to develop risk assessments known as patient risk stratification. However, the challenge is that there’s a dearth of risk stratification methodologies that can cause confusion and undermine patient trust. Moreover, there’s often a lack of clarity about how payers use risk assessment tools to determine patient risk stratification.

Patient risk stratification “can be a source of confusion for both patients and providers,” Richter Weber noted, “but it’s an essential part of value-based care. It’s an area where education is really critical and [there’s a need] for more transparency about the threat of data inaccuracy and unavailability and the risks to value-based operational success.”

Another issue is that the data collection necessary for patient risk stratification is not always supported by EHRs, which typically don’t trigger reminders to support care coordination. Payers also generally don’t have a way to obtain this ever-changing data, which makes it onerous to conduct risk stratification.

CAQH CORE recommends:

1. Expanding industry awareness regarding data inaccuracy/unavailability and how different methodologies can affect value-based payment operational success.
2. Advocating for industry collaboration and transparency concerning risk stratification models and their content.

Provider attribution 

In value-based care, providers oversee the care of specific patient populations, and the linking of patients to providers is known as attribution. In turn, the metrics that support value-based care — such as distribution of shared savings/risk, outcomes and total cost of care — are attributed to patient health data. However, many providers may be unclear about their attributed patients or how patients are matched to them, making it more difficult to manage patients’ care.

This may occur when providers bill under several tax identification numbers (TINs) or under TINs that designate identification at the group or organizational level. There also are an inordinate number of attribution methodologies.

 “There’s no standard attribution methodology,” Richter Weber asserted. “When we talk to the health plans in our research, what they told us was 95% of the time all the attribution models are about the same. … But what we heard from providers is that 5% makes a big difference.”

CAQH CORE recommends:

1. Enhancing provider awareness of patient attribution through clearly defined and precise provider data.
2. Streamlining and improving transparency when using attribution models.

Quality measurement 

Another important aspect of value-based care is successful measurement of process performance and outcomes. However, providers can be overwhelmed when weeding through numerous quality measures. According to a study conducted by the National Quality Forum, in the second quarter of 2014, 33 CMS programs featured more than 850 distinct measures, only a third of which were employed in three or more CMS programs.²

Likewise, the amount of time providers spend on assembling quality data reports for value-based initiatives can be cumbersome. Per a 2015 report, physicians and staff devoted 15.1 hours per week to reporting quality measures from external entities. In addition to time, some quality measurement data is not available via EHRs and the data collection process is rarely streamlined.³

 “While quality measures are technically clinical in what they’re measuring, the exchange and tracking of them is an administrative burden,” Richter Weber said of the importance of this issue. “And we heard this loud and clear from the providers.”

CAQH CORE recommends:

1. Backing industry efforts to focus on challenges presented by quality measures and promoting uniformity through education to:

• Help make quality measures consistent across programs.
• Lessen the burden on providers when collecting quality measure data.
• Ensure that quality measures are actionable.

 
Until the healthcare industry comes together, progress toward adoption of value-based care will be protracted. However, by collaborating and focusing on value-based payment operational processes and opportunity areas, providers and other industry stakeholders can ensure a smoother transition.

Dig deeper

• For more insight on streamlining the exchange of value-based payment information, access CAQH CORE’s report All together now: Applying the lessons of fee-for-service to streamline adoption of value-based payments: bit.ly/2E6HL4d.

Notes:

1. “Measuring progress: Adoption of alternative payment models in commercial, Medicaid, Medicare Advantage, and fee-for-service Medicare programs.” Health Care Payment Learning and Action Network, 2018. Available from: bit.ly/2JL1uwI.
2. Measure Application Partnership, National Quality Forum. “Cross-cutting challenges facing measurement: MAP 2015 guidance.” Final Report. March 2015, 7.
3. Casalino LP, et al. “U.S. physician practices spend more than $15.4 billion annually to report quality measures.” Health Affairs, 35, no. 3 (2016):401-406. Doi: 10.1377/hlthaff.2015.1258. Available from: bit.ly/2YuQ0Bs.