Your VBP team needs to think strategically about their access to data and analytical capabilities to support successful engagement in VBP models.
Being able to access and analyze administrative, clinical, and financial data is important for provider entities participating in value-based payments. While a payer can provide you with data, it is important for you to be able to make use of the data once provided. VBP success requires skilled analytical and data support infrastructure staff that can assist clinicians in understanding what data can be leveraged, when and how. It is also important for you to understand what data are essential to share with the payer(s) in order to meet quality and other VBP performance benchmarks.
When first starting VBP models, you and your payer(s) may not have all the required data to measure quality performance. Some payers include quality measures in the first year of a new VBP program that are for reporting purposes only. This allows provider entities and payers time to gather data to set benchmarks and the opportunity to identify efficient ways to collect and submit the data before financial incentives are linked to performance.
When taking on episode, shared savings, shared risk, or capitation VBP arrangements, consider the following data capabilities:
- A formal data and health informatics plan that includes a strategy for collecting and analyzing attribution, administrative, clinical and financial data relevant to the VBP model and population;
- Appropriate software to receive and analyze administrative, clinical, and financial data, and
- The ability to access key clinical data elements including medical records, medications, test results, prescriptions, demographics, vital signs and care plans to facilitate care management and other clinically related activity.
VBP Toolkit Menu
- Understand VBP models
- Educate your team on VBP terms and models
- Assess internal interest and understanding of VBP
- Assess your readiness for a new or modified VBP model(s)
- Identify current data analytical capabilities and gaps
- Understand member attribution and assignment
- Understand your population and health disparities
- Understand types of financial risk in VBP models
- Get ready for VBP
- Go live with VBP model(s)
- Promote provider clinical transformation to foster VBP success
- Access technical assistance and peer learning
- Understand how quality is measured and used in different VBP models
- Maximize quality improvement – performance on measures
- Review results and make modifications
- Scale up current VBP contracts and engage additional payers
- Understand VBP compact models
- Primary care model
- Specialty care models (future content)
- Hospital care model (future content)
Invest in data analytics and obtain access to analytical platforms
Performance measurement is an integral part of VBP arrangements, both in determining the payments themselves and evaluating the success of the program. Data sharing, analysis, and transparency in measurement methods are essential for both providers and payers operating under these arrangements. Data analysis also allows you to make informed decisions when considering and implementing new strategies for new VBP arrangements.
Your internal data analytics staff will manage complex data sets, complete analysis of clinical data and the development and interpretation of provider-level quality and cost performance measurements. More specifically, you need tools, data infrastructure, and payer support to be able to routinely handle the following capabilities on behalf of practices and clinicians:
- Ability to pull a list of patients/members attributed or assigned to each practice/clinician as applicable, including relevant demographic and geographic data
- Ability to stratify this attributed or assigned population based on specific risk criteria (payers may use specific diagnosis-based tools that allocate members based on risk scores into groups such as low risk, medium risk, rising risk and/or high risk in terms of potential for costly utilization)
- Ability to promptly access/share data on member utilization and outcomes with the care team
- Ability to quickly communicate gaps in care at the point of care
- Ability to aggregate clinical and other data from multiple sources (such as practices integrating data from external portals, such as PreManage)
- Ability to submit custom reports to payers for metrics management and to meet VBP targets
Other data and analytical capabilities that are helpful to have but may not be essential at the beginning of your VBP journey include:
- Ability to visualize near-to-real time data at the provider level for dashboarding and continuous quality improvement
- Ability to obtain, share and aggregate additional demographic information including findings on health-related social needs
Payers typically utilize analytical platforms that can produce actionable reports to assist provider entities in understanding the care needs of the population for which they are held accountable under the VBP arrangement, and the anticipated medical expenses. Some payers can offer providers access to health plan data from a web portal or direct data feeds. These portals and data can help provider entities to monitor and improve patient care. Portals and processes may also serve as a platform for provider entities to transfer VBP-related data for payer use. To understand how useful the payer portal will be, ask your payers what information is available on their portal and how timely it is updated.
Larger and more sophisticated provider entities may consider investing in analytical platforms when seeking to sustain and expand advanced VBP models. However, having new analytical platforms or a new electronic medical record system is not a magic wand to solve all data and analytical needs for VBP success. Where feasible, enhance internal data systems for analytic capabilities such as:
- Provider entity and clinician-level performance on key quality indicators against benchmarks, and compared to prior performance periods
- Stratification of quality performance by patient demographics (REALD and SOGI) and health-related social needs that identifies disparities
- Financial information on costs relevant to the payment model
- Reports on key areas that could spur action to improve quality and reduce cost such as:
- Predictive modeling of high-risk patients
- Avoidable Emergency Department (ED) visit opportunities, by condition
- Medication refills
- Gaps-in-care reports
Children’s Health Alliance (CHA), a pediatric independent practice association (IPA) in the Portland metro area, utilizes a population health tool that combines data from multiple sources (EHR, claims, hospital ER and inpatient visits from PreManage) to allow care team members to see the complete picture of the patient’s health care utilization. By ingesting health plan rosters and attributed population, it allows providers to review important utilization and quality indicators for all of their patients across payers and see the most recent health activities such as provider visits and emergency room discharges. CHA has created dashboards to summarize quality and utilization measures by payer and work lists that identify patients in need of outreach for care gap closure, onboarding, or follow-up.
Episode-Based Payments: A fixed dollar budget target (or payment amount) that covers a set of services for a defined period of time. A payer may pay providers on a FFS basis with retrospective reconciliation to the episode/bundled payment budget at the conclusion of the performance period.
There are generally two types of episode-based payments:
- acute care episodes or events, which include services related to a condition or procedure (e.g., joint replacement, colonoscopy, pregnancy & delivery), and
- chronic condition episodes, which include services for a fixed amount of time related to a chronic condition (e.g., one year’s worth of care for a diabetic member).
Capitation: Capitation is when one or more providers receives a lump sum payment at the beginning of a set period of time for a specific set of services of an attributed population.