Even as payers plan to invest in initiatives to accelerate value-based care delivery, research shows that progress seems to have plateaued. In a recent survey from Becker’s Healthcare and VirtualHealth, payer organizations revealed these top barriers to implementing value-based care:
- Communication barriers between payers and providers
- Disparate systems and data formats that create silos of information
- Lack of active patient engagement
- Gaps in the proactive whole-person care approach — specifically those related to social determinants of health
- Poorly constructed workflows
What’s more, 43% of payers said they’re struggling with care coordination.
A lack of data interoperability was cited as central to many of these challenges. Allowing health plans to share data freely but responsibly should be the goal – but payers and health systems need robust infrastructure to ensure that data flows to the right place at the time, and building that infrastructure takes time. Additionally, many respondents expressed concerns over technical alignment and prioritizing efforts around this goal over the next few years.
Following this survey, VirtualHealth hosted a webinar with Becker’s featuring speakers from Itiliti Health, Blue Cross Blue Shield Michigan, Innovation Care Partners, and Blue Cross Blue Shield North Carolina.
Below we examine some of the questions discussed during the webinar, highlighting key answers and expanding on some of them with the expertise of Dr. Lee Mills, former Senior Vice President and Chief Medical Officer of CommunityCare in Tulsa, Oklahoma.
What Are Payers’ Top Priorities for Improving Care Management and Population Health?
Using Data to Identify Care Gaps
Michelle Fullerton, Vice President, Care Management, Customer Consulting, BCBS MI:
“Our healthcare system and processes are very complex. It goes beyond when [a patient is] in the hospital. It means working with physicians, outpatient, outpatient surgeries, inpatient, medications, specialties, population health, and social determinants of health. And it’s really identifying as best we can using data, a lot of data, to identify patients who have gaps in care.”
The Power of Population Health Interventions
Natosha Anderson, Associate Vice President, Population Health, BCBS NC: “You can have broad improvements in health and overall well-being in a community with a well-designed population health intervention. The focus on care management and population health is smart. When you invest in these types of services, you’re investing in the long-term benefits of improving the overall well-being of members over time. This, in turn, helps keep healthcare costs down. So as organizations plan for the next five to 10 years – if they’re interested in being a part of the solution to bend the healthcare cost trajectory – it’s wise to invest in these long-term solutions.”
How Can Payers Address Care Coordination Challenges?
Sharing Data to Build Trust
Michael Lunzer, Founder and CEO, Itiliti Health: “In our relationship with VirtualHealth, we’re striving to enhance interoperability and deliver real-time information to people. Part of the initiative is helping payers and providers build trust and transparency with one another. One of the barriers to care management oftentimes is that the provider is skeptical about what the payer is trying to accomplish, and wants to have a partner, not an adversary. [This stresses the need for] interoperability. The goal of that interoperability is sharing good information so that providers and payers trust each other. And in that way, you see much more effective care coordination and care management.”
Improving Data Interoperability to Ensure the Right Care at the Right Time
Roberta Kafora, Director of Care Coordination, Innovation Care Partners: “I completely agree about the need for interoperability, because it does provide that communication across the care continuum that is needed to ensure effective collaboration and coordination of care. We don’t always know where a patient is. So having that direct feed to be able to locate that patient – perhaps they’re in a skilled nursing facility, but we don’t know where to reach out and wrap our hands around that patient to bring them back into the community setting. If money were no object, it would be great to have multifaceted interoperability that would provide all of that direct feed to our care team so we could ensure that our patients are receiving the most appropriate care at the most appropriate time.”
How Is Your Organization Navigating Top Barriers to Value-Based Care?
Integrating Care Management in the Provider Community
Michelle Fullerton: “We have a program called provider-delivered care management, where Blue Cross Blue Shield of Michigan pays providers to have case managers in their practice. And then we integrate the health plan’s case management program with the providers. We can help those provider-delivered case managers with things like benefits and continuity of care, or what the employer of this patient provides for additional assistance. Working with our providers and double delivering provider-delivered care management through the health plan, has become a wonderful program because we just try really to capture a patient where they are and address that need.
Also, a really important piece of care management is [reaching people] upstream. How do we identify patients before they become high-cost patients, or how do we avoid the troubles that we know they’re headed into if we can close those gaps in care and work with our provider community?”
Ensuring Data Transparency to Improve Provider Relationships
Natosha Anderson: “Blue Cross Blue Shield of North Carolina has leaned into our provider-partner relationships and worked hard to establish a cadence of clinical collaboration where our care management teams talk to one another. We share information, share insights, and best practices, as well as create space for our community of provider collaborators to share best practices with one another.
I think data analytics and interoperability are where the critical components of those partnerships have to be. If we can’t share data [then] it’s really difficult to move the needle on value-based care; it’s really difficult to collaborate and exchange data in a way that benefits the member. So that’s really where data and technology come in, to build the foundation of those relationships and improve those partnerships.”
Dr. Mills: “Overcoming obstacles and fostering trust is essential to cultivating collaboration among all care participants. And that’s a lot of people: nurses, physicians, specialists, social workers, care managers, community-based professionals and volunteers, and more.
The ability to seamlessly share data and information is critical to forging trust between these key players. Technology will be pivotal here, with payers needing to leverage data management, analytics, and interoperability solutions.”
What Opportunities Does Technology Offer Payers?
CMS Interoperability Ruling and FHIR
Sue Powers, Chief Growth Officer, Virtual Health: “Interoperability has always been a pain point and integration has always been a pain point. But an opportunity is CMS’ interoperability ruling, [which is] helping drive the industry. FHIR [is] going to help drive the industry to a common standard to make real-time interoperability an actual reality for us in the not-too-distant future. So I think that piece of the technology is important because that brings all of the data to the front for the people who need it in a timely manner.”
Centralizing Member Data
Michael Lunzer: “From our perspective, making sure that these fragmented siloed data systems come together into a common platform [is critical]. Between VirtualHealth and Itiliti Health, we’ve utilized FHIR at our existing payer customers to centralize that data in VirtualHealth* and make it easy for everybody to access. Extending this siloed data into a central point that makes it easy for all parties to access generates a lot of satisfaction, it makes information timely. And that’s ultimately what members are looking for.”
*Lunzer is referring to HELIOS, VirtualHealth’s medical management platform that enables payers to quickly and easily connect all of their critical data sources and convert all inbound data to formats that meet the FHIR standard.
Leveraging Data to Provide Whole-Person Care
Michelle Fullerton: “[Holistic patient data] needs to be at the fingertips of the case manager that’s working with the patient. So I would say the million-dollar need is to get all of that information – and not just claim information, not just medical information – but all of that information, [including] population health information and social determinants of health information. There’s a lot of information that’s not in a code, and not in a claim, and not in a bill. When you talk to a member one-on-one, you start to learn about all the things that can affect their care. They have no food in their home, they can’t afford the medications that had been prescribed. That is something that you have to pull out of a conversation with a patient, right? So that’s the million-dollar need, is that things and data that today cannot be codified needs to be codified so that we can get it into a system so we can look at a patient holistically and then across the continuum of care.”
How Do You See Value-Based Care Evolving Over the Next Decade?
Using AI to Improve Member Engagement – and Outcomes
Natosha Anderson: “Health plans can invest in technology like AI to support care management and value-based care – they’ll see improvements in health outcomes and ROI. We’ve seen it at Blue Cross Blue Shield of North Carolina, both in our value-based care arrangements and in our integration of AI machine learning into our care management, identification, and stratification models. We saw a significant increase in engagement in our programs, reduction and avoidable admissions, readmissions, and cost savings.”
Reducing Administrative Burden for Clinicians
Michael Lunzer: “Technology is not ultimately a decision maker. It is an augmentative tool, not a replacement for nurses. As we think about the journey from where we are to where we want to be, ultimately, if we can strip away all of the administrative burden from those nurse care managers, that’s the Nirvana. Today, they spend a lot of time navigating systems to gain information. If we can leverage interoperability and these great tools to give them immediate information, that’s a huge win. The biggest improvements will come from the interoperability and transparency of data. And then blending in AI.”
What Does the Path Forward for Payers Look Like to You?
Individualized Care Planning Backed by Member Data
Michelle Fullerton: “What is most important is whole-person health – looking at each patient as an individual, and helping them to better control their own healthcare and be an active participant. in their own healthcare. And it takes a team-based approach, and data is formative. But it really is the hard work of the clinicians working one-on-one with a patient to understand their motivations, their life experiences, and their needs that help guide a solid plan of care. And the plan of care needs to be not just from a hospital discharge or not just from a doctor visit, but encompassing their day-to-day life, their work life, their family life, and their mental health; all of that has to be combined.”
Closed-Loop SDOH Support
Roberta Kafora: “We also really need to focus on the social determinants of health and ensure that we have strategies in place to close the loop on those social needs of our patients. The social determinants that we find for our patients have such an impact on their overall health and well-being. Ensuring that we have those resources and that we do those assessments on a continual basis [is essential].”
Improving Data Practices to Surface Members with Immediate Needs
Michael Lunzer: “I think the heavy lift for payers in the future is bringing that data together. To get to this wonderful future where nurses can leverage data and really deliver care to the member, there needs to be a central repository of that data. Integration and interoperability is really key to allowing a centralized point of data access to find those patients most in need of live support, and then also warm them up for that live support.”
First, Rework Processes
Sue Powers: “When I talk to different payers and healthcare organizations, a lot of time what hits me is that the processes and the workflow in place have been around forever. When we’re talking about value-based care and moving forward, those processes need to be reworked. They need to be looked at from a perspective of proactive, whole-person care. That’s number one: Look at those processes in the workflow before you look at technology. Once you’ve done that, then look at your technology, and look at technology that can complement and enable these new processes and workflows.”
Finding the Right Solution to Address Barriers to Value-based Care
Dr. Mills: “As panelists emphasized, data visibility and interoperability will play a critical role in enabling payers to break down barriers to value-based care. It’s needed to empower clinicians to work at the top of their licenses instead of spending the majority of their time navigating disparate systems to track down member information. It’s critical to building trust between providers and payers. It can help drive member engagement and satisfaction.
The right solution will, critically, centralize member data on a single platform accessible to a member’s primary physician, specialists, care manager, social worker, nurses, and others. That way, these stakeholders will be able to instantly see emerging diagnoses, critical test results, interventions and treatments ordered, and any challenges regarding social determinants of health that have surfaced.
Availability of this information – without the need to waste time tracking it down in multiple systems and silos – is key to allowing clinicians to make decisions that prioritize member health and well-being.”
A solution to support the delivery of value-based care should:
- Facilitate data management at a population level and an individual level
- Complement and automate workflows
- Ensure FHIR data compatibility for improved interoperability
- Provide closed-loop reporting on meeting SDOH needs
- Provide multiple ways to communicate with members to build relationships and engagement