Value-Based Contracting: The Role of People, Process and Technology – For Payers

By Chris Bethell
read

Value-based care (VBC) contracts are here, but how do you, the payer, foster success for both you and your provider network as you transition? Understanding how the people, process, and technology intersect is critical to succeeding in VBC.

The People

At the heart of VBC is the quadruple aim (reducing costs, improving patient experience, improving population health, and improving the provider experience). Each of these aims impact a different stakeholder group whose concerns, contributions, and goals need to be taken into account in each contract. You, the payer, hold the information that allows the other stakeholders to stay connected throughout the care journey.

Patients are another key player in the VBC process. Today’s patients are active participants in their care—mindful of cost and quality while seeking out a positive overall healthcare experience.

There are also community-based organizations (CBOs) and social workers, who are both leaders in organizing interventions that meet the non-medical needs of high-utilizers. According to researchers, medical care is estimated to account for only 10-20% of the modifiable contributors to healthy outcomes for a population.[1] The rest fall under social determinants of health (SDoH), which include behavioral, socioeconomic, and environmental factors like smoking, income, housing, and transportation.

Lastly, there are providers. They are responsible for monitoring their patients’ progression throughout their care journey. Providers need to play an active part in the contracting process so they can be positioned to better meet the needs of their patient population.

The Process

  1. Change Your Perspective

Transitioning to VBC requires a fundamental change in how care is viewed and delivered. Unlike fee-for-service (FFS), reimbursement isn’t cut-and-dry. You need to focus on achieving the quadruple aim in a way that benefits both payers and providers.

  1. Ensure Contract Goals Are Achievable

All contracts have one thing in common: they pay providers based on specific measures and metrics including quality, cost, and patient experience. The top five contract types are:

  • Accountable care organizations (ACOs) - 62%
  • Medicare episode-specific bundled payment models - 51%
  • Patient-centered medical homes (PCMH) - 35%
  • Capitation - 29%
  • Commercial bundled payment contracts - 25%[2]

(To read more about each contract type, check out the full-length eBook version of this post)

To determine which value-based contracts are right for your providers, you need to determine the needs of their populations, identify gaps in care that will hinder success, and evaluate their technology and resources.

  1. Engage Your Providers

As a sign of good faith, your contract negotiations should take provider concerns as equally into account as your own. Payers and providers play different roles and oftentimes differ on what constitutes risk or value. To bridge these differences, you want to ensure that your value-based contracting process is transparent. Then you can both be in agreement on how provider performance will be evaluated and how they can expect to be reimbursed for their services.

The Technology

To successfully negotiate value-based contracts, you’ll need freely shared data, historical trend analysis, population risk analysis, and the ability to determine where resources can be allocated to create the highest possible impact.

VBC has been criticized by some for having a poor incentive structure and implementation.[3] Predictive modeling tools can bridge that gap leading to better results.

Most importantly, your analytics tool needs to be simple enough to use to avoid provider burnout. A 2015 report outlined the leading causes of physician burnout, with four of the five coinciding with VBC.[4]

The transition to VBC requires additional electronic health record (EHR) documentation, which can also be associated with an increase in practice computerization and bureaucratic tasks, leading to longer work hours and feelings of being underpaid.[5] Technology should be a tool, not a burden, for your providers so they can deliver the highest level of care possible within contract terms.

How Spectramedix Can Help You Succeed

The SpectraMedix VBP Performance Suite provides an integrated ensemble of applications designed to streamline the VBP journey for health plans and their provider networks.

  • The VBP Contract Navigator streamlines the value-based contracting process, providing a collaborative solution to design, evaluate, negotiate, and reconcile mutually beneficial risk-based contracts.
  • The VBP Performance Portal is tailored to drive higher quality and improve financial performance during and beyond the transition to value-based payments.
  • The VBP Cohort Manager helps you easily assemble a group of members with specific conditions, assign them a care team, and drive interventions to deliver cost-effective, high-quality care.
  • The VBP Self-Service Analytics Solution is an agile data framework that allows your team to use their BI tool of choice to dig deeper, expand horizons, and find new ways to further improve performance in the VBP world

Value-Based Contracting Savings Calculator CTA-1

[1]https://nam.edu/social-determinants-of-health-101-for-health-carefive-plus-five/

[2]https://markets.businessinsider.com/news/stocks/new-market-survey-findings-reveal-opportunities-and-barriers-to-adopting-value-based-payment-models-1028980857

[3]https://www.amga.org/amga/media/pdfs/about%20amga%20
family/family/consulting/riskpaper2019.pdf

[4]https://www.medscape.com/viewarticle/838437

[5]https://www.forbes.com/sites/forbestechcouncil/2018/08/24/
health-cares-physician-burnout-part-two-is-technology-the-cause-orthe-solution/#49f5e6a5206