- In new guidance for healthcare providers and payers, the Health Financial Management Association (HFMA) has called for improvements to the mechanisms and strategies for health data exchange in order to support the transition to value-based care.
"Health plans, hospitals, and physician practices need to collaborate to create equitable payment models that reward all stakeholders only when high-quality, resource-efficient, cost-effective care is provided to the patient," the report states.
"Successful models," it continues, "will require the flow of financial and clinical data among internal and external stakeholders to efficiently manage care, transfer the appropriate type and amount of risk to providers based on their financial wherewithal, and engage patients in care processes."
The HFMA report, the first in a four-part series on value-based care, shines a light on the potential for claims data to improve resource use and drive down cost:
The “virtual delivery network” of a hospital or physician practice has a significant impact on the longitudinal cost of care to purchasers. Giving providers access to knowledge distilled from claims data allows them to identify opportunities to reduce unnecessary utilization—and, in turn, the total cost of care—through alignments with high-quality, cost-efficient organizations across the continuum.
In addition, the report calls for health plans to give provider participants in value-based care models access to claims data — "both raw claims feeds and aggregated management reports" — to allow the latter to derive their own insights.
"While access to longitudinal claims data allows hospitals and physicians to retrospectively identify opportunities to improve care, access to real-time clinical data allows for faster interventions that prevent unnecessary utilization, improve outcomes, and in some instances (particularly with medications) save lives," the authors of Health Care 2020 contend.
However, these same authors admit that a lack of health IT standards and other mechanisms to support health IT interoperability continue to hold back providers:
Seven years after the HITECH Act and its associated funding and penalties, the sort of interoperability standards that would allow real-time access to clinical data remain elusive for most providers. Hospitals and physician groups must push their vendors to provide true data interoperability across electronic health record platforms—without additional financial costs. Regional health information exchanges (RHIEs) also are part of the solution, but their promise has remained largely unrealized for want of a sustainable business model and development of a unique patient identifier.
HFMA places the onus on healthcare organizations and providers to demand interoperable health IT solutions from their EHR vendors. "Hospitals and physician groups must push their vendors to provide true data interoperability across electronic health record platforms—without additional financial costs," it advises.
That said, it pegs all healthcare stakeholders with the responsibility of developing unique patient identifiers — that is, methods for patient matching and reconciliation — that balance efficient health data exchange and health data privacy and security.
Despite the clear support for value-based care models, the HFMA guidance urges caution with respect to implementing these risk-based arrangements.
"Outcomes-based payment models need to be designed such that they transfer only the technical risk associated with delivering care, as opposed to insurance risk," it reads. "Even with risk transfer limited to technical risk, hospitals and physician groups need adequate reserve capital or a repayment mechanism available in their contracts to ensure they can sustain losses and remain economically viable."
Earlier this year, the authors of a study in the Journal of the American Medical Informatics Association sought to identify factors preventing payers from participating in health information exchanges and ultimately found large gaps in payer HIE expectations and the business models employed by operational HIEs.
They concluded that payer participation in health data exchange could worry providers, but that forms of value-based care — namely accountable care organizations — could go a long way toward easing those fears.
"While payers claim to have the right intentions for seeking greater access to clinical data, as long as reimbursement rates are regularly renegotiated, providers have reason to be skeptical of payer involvement in HIE," they wrote.
"The key to breaking this stalemate may lie in the rise of ACOs and other risk-based contracting approaches, especially if they are negotiated for multiple years at a time. For providers, this increases the value of more timely access to claims data, as well as decreases the need to limit payer access to clinical data (to prevent profiling or impede fee negotiations)."