If Data Is The Path To VBR, Technology Is The Guide

By Monica E. Oss, Chief Executive Officer, OPEN MINDS

Technology is one of the issues that keeps chief executive officers (CEOs) up at night. Creating a hybrid service delivery system with a great consumer experience and managing value-based agreements are two challenges than many specialty provider organization executive teams are grappling with. In fact, a recent survey found that 60% of CEOs identified acquiring new technology and putting that new technology to use as a “top of mind” concern.

And those concerns fall in three areas—data, talent, and budget. Sixty-eight percent of CEOs are concerned their organization doesn’t have the budget for the technology they need. And 64% are concerned about the quality of the data they have for decision making.

In the midst of this transition to an integrated, hybrid, consumer-centric, value-based, market landscape, where do executive teams start on the path to building the digital platform they need? That was the focus of a Qualifacts-sponsored web briefing, Don’t Leave Money On The Table: How The Right Technology Can Improve Your VBR Success, which featured Capital Area Human Services (CAHS) Director of Business Development, Karla Lee-Muzik, and Program Manager, John Nosacka. Their focus was on how to leverage existing investments in electronic health record keeping systems (EHRs) as a core technology for both organizational performance management and the management of VBR arrangements.

Established in 1997, Capital Area Human Services (CAHS) is a substance abuse, mental health, and developmental disability provider organization serving the Baton Rouge, Louisiana area. Their programming spans first episode psychosis programs, jail reentry initiatives, primary care, drug court services, case management, wraparound services, and more. Each year, they serve over 10,000 clients. CAHS’ first VBR contract was a value-based purchasing contract with a health plan that focused on six HEDIS measures and two other metrics with an impact on the overall pmpm health care spend of consumers. They now have additional value-based contracts for both physical health and behavioral health services.

Using the data to drive consumer care management: In their work with health plans, the CAHS team was focused on consumers with serious mental illness (SMI), especially their high utilization rates and varying medication compliance levels. A key to consumer care management was both capturing the data in their EHR, and integrating that data with information from other sources to identify when and what intervention is needed to improve consumer outcomes. For example, Ms. Lee-Muzik recommended integrating electronic prescribing data with EHR data to track medication compliance. This allows the team to identify who is not adhering to recommended medication regimes and address those issues quickly.

Tracking the performance metrics that matter: Any value-based arrangement is focused on a set of performance metrics that defines the relationship between the health plan and the provider organization. In its current arrangements, CAHS needed to shift their focus to HEDIS measures. To do this, they captured information on ER visits, inpatient stays, medication compliance, client appointment attendance, and 30-day readmission rate. They emphasized that the key is to capture performance data in real-time so the team has the opportunity to improve performance throughout the contract year. To do this, CAHS created a quality incentive performance department (QIPD) that serves as a gatekeeper of its value-based programs. The key focus of the department is getting data from the health plans that can be used to improve care management.

Currently, two areas of focus for improving performance are facilitating medication adherence and increasing the use of outpatient services—both to reduce per member, per month spending. Ms. Lee-Muzik said, “If you can do good outpatient care and make sure that they are educated on their medication management and develop good rapport, and stay on their medication, then you will have decreased the overall Medicaid spend for the high-cost dollars of inpatient utilization.”

The lessons learned: The CAHS team had two big takeaways from their VBR ventures—start small and invest in the right technology. CAHS found that different payers can want different things, and just what those things are depends on how their programs are defined. Noted Ms. Lee-Muzik, “We were having to change gears in how we address processes and problems in order to be successful.” She recommended that others looking to enter the VBR space start small and look at the opportunities that they think their organizations will be successful at because, “You build on your successes with your value-based programs. Once you have those successes under your belt, you can use those to catapult opportunities with other payers.”

Another lesson—technology is a must as manual tracking and documentation won’t cut it. Delivery of services to so many people with differing diagnoses and compliance levels can be difficult, and organizations don’t have the staffing levels needed to manage it. “Without the use of technology, we found early on that manually manipulating data, running spreadsheets and merging spreadsheets, and trying to keep up, we felt like we were chasing the numbers instead of being able to command the numbers,” said Ms. Lee-Muzik. Monitoring and managing thousands of clients to the level needed is not possible manually.

As we look ahead to a 2023 with tighter health plan margins and more payer focus on cost containment, provider organization relationships with health plans are likely to focus more on performance—and tying referrals, revenue, and reimbursement to that performance. To be prepared, executives of specialty and primary care provider organizations need to understand the performance metrics that matter to the health plans in their markets—and build the EHR functionality extensions that allow them to build successful partnership relationships.