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By Carol Clayton

Translational Neuroscientist for Relias Learning

Value-based Purchasing. The Future is Here. Prepared?

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Put yourself in  two scenarios:

Scenario 1:

You are with a large provider agency that spent the last 18 months implementing an electronic record system across 11 sites and three service lines. You just received a Medicaid notice stating that, effective July 1 of this year, your agency will be under a performance-based payment model for a portion of your business. Twenty percent of your fee for service (FFS) dollars will be withheld until key performance indicators are met, so you need a system to track and report on the key measures. They will be analyzing Medicaid services for 2,000 of your enrolled consumers — roughly thirty percent of your total consumers, and the withholding will be released at 18 months pending your results.

Scenario 2:

You are with a large provider agency and after three years of negotiation with your largest payer you won a contract to provide care coordination services for 1,800 consumers with multiple, complex behavioral and physical health needs. The payer plans to track performance metrics, tying them to improvement in health care gaps and medication adherence for chronic health conditions. You must report on these metrics monthly for the 1,800 people you serve. You receive a per member per month (pmpm) rate for every enrolled consumer of the 1,800 to provide these services. Thirty percent of them are not currently enrolled in your agency services.

I’m guessing these scenarios aren’t new for you as we see them frequently with large provider agencies. Both require using population health data to drive clinical actions and report on results, and both will also require reporting at the population health level (i.e., across the entire population enrolled in the value-based arrangement).

Value-based purchasing and population health management

How does a provider shift from fee-for-service management to population health value-based outcomes management? What tools can you use for this transition?

Here are the top five requirements of technology solutions for value-based purchasing paradigms:

  1. Features prebuilt, easily configurable algorithms for tracking on key performance indicators.
  2. Offers the ability to track and report on the metrics at the population health level along with subpopulation and individual consumer tracking.
  3. Minimizes manual data entry by staff.
  4. Optimizes expensive clinical resources by providing consumer patient registries presorted by condition, care gap, performance measure, and associated costs for easy identification, outreach, and engagement tied to clinical and cost improvements.
  5. Allows you to see all care for a consumer or group of consumers, including services provided outside of your system for a 360◦ view of patient care.

Additionally, several necessary adjustments are required by Value-Based Purchasing paradigms requiring staff to:

  • Work across multiple technologies.
  • Adapt how daily work is done — from scheduling, billing and tracking productivity to engaging in care coordination activities.
  • Follow or encourage evidence-based protocols that reduce clinical variation, a key cost driver.
  • Keep their cool and enthusiasm during a change process that requires staff to work within both paradigms.

Taking the next steps

These scenarios are challenging, especially for frontline staff who struggle with toggling IT systems; hesitate in changing clinical practices to follow data driven, evidence-based protocols; and constantly address alerts and metrics that “need attention.” Moreover, staff members are often at a loss on how to change work processes in meaningful ways for successful population health management and service delivery. They are flooded with data and action items but at a loss as to “what to do.”

Here are a few key steps for successful evolution to a population health paradigm to sustain business, manage the change process, and prove outcomes for value-based payments.

First, know when to look beyond your electronic record system for tools that support the new value paradigm. The electronic record, combined with HIE participation, allows you to aggregate and see data at the individual patient level beyond your own internal system.  For population health approaches, a tool that aggregates all data across the entire population, then applies analytics that provide actionable insights (including those that reduce clinical care variation and low impact services) is required.  The tool must stratify where to start — based on performance reporting requirements, cost improvement opportunities, and poor care and outcome risks — and provide decision support as to “what to do.”

The second step is to identify a clinical lead to drive system change at the clinical level. Change processes are not driven by the IT Department or by standing up a population health tool and saying ‘go for it.’  Ultimately, any population health approach requires engaging with and attending to the needs of an individual consumer.   The most successful transitions I have seen are those led by a credible clinical or quality leader, supported by advanced technology, and a persistent implementation science approach wrapped with continuous learning throughout the change process.

Editor’s Note: Carol D. Clayton, PhD, is a Translational Neuroscientist for Relias Learning and former CEO of Care Management Technologies ( Carol leads a workshop on Wednesday, April 5 at NatCon17:  Beyond The EHR: How Providers Use Population Health Data to Improve Care and Win Business.