By Tawnya Bosko, PhD, DHA
Vizient Senior Principal, Value Transformation & Payer-Provider Alignment
Providers are being asked to take on more financial risk by payers, moving from fee-for-service to value-based care payment models across all lines of business. Following Medicare's goal of having 100% of traditional Medicare beneficiaries in an accountable care relationship by 2030, other payers such as Medicare Advantage, commercial and Medicaid plans also are placing responsibility on providers to manage beneficiary cost and provide high quality care.
Provider success is dependent on having a clear view of their performance throughout the year and thinking innovatively about how to approach payer negotiations. Providers must use claims, clinical data and benchmarking services to navigate blind spots and refine improvement efforts.
These five innovative strategies for your Population Health Informatics and Technology (PHIT) team can help leverage data and maximize your organization's potential with payers.
- Custom regional utilization benchmarking: Understanding where your health system excels and where there are opportunities compared to benchmarks will help drive improvement efforts to support your value-based care goals. Finetune your approach to utilization benchmarking with regional and national trends, risk-adjusted for your population. This can help identify where there may be overutilization in high-cost avoidable care areas such as ED visits, post-acute care and home health recertifications. It also can pinpoint providers or clinical condition outliers that need attention or, conversely, where you stand out in the market as a top performer.
- Market payer rate benchmarking: Effective July 1, 2022, Centers for Medicare & Medicaid Services' (CMS) Transparency in Coverage rule went into effect, adding health plan data to the Hospital Price Transparency Act. Health plan compliance is strong due to large noncompliance penalties, but the large unstructured data sets have mostly benefitted payers, who have the resources to ingest and analyze the rates. However, health systems who partner with data aggregators or consulting firms to compare their commercial rates will come to the negotiation table informed with data to drive maximum reimbursement, especially if that information is paired with a confident value proposition for the population they serve.
- A solid value proposition: Health systems must know their value within the new normal of payer contracting: a landscape focused on cost and quality. A data-driven value proposition can lead to more informed contracting negotiations, attract new care partners and appeal to knowledgeable consumers. Equipped with where they excel in utilization benchmarking performance and where there are opportunities in market payer rates, health systems can begin to tell their value proposition story to payers. Other considerations to highlight your capabilities in value-based care include:
- Have you been successful in achieving shared savings in the Medicare Shared Savings Program (MSSP)?
- Does your organization have lower readmissions and complication rates while moving unnecessary admissions to the ambulatory environment?
- Do you have a strategy for increasing annual wellness visits and accurate documentation and coding?
- What volume shifts are you expecting in your market over the next 5 to 10 years?
Your population health data strategy should bring these elements to the table to garner payers' trust in your system capabilities as you negotiate for your desired terms and rates.
- Timely performance projections: By using actuarial services to report on incurred but not reported (IBNR) claims data to project performance, an organization can understand how they are performing against their financial target throughout the performance year. Direct data feeds, such as CMS' Beneficiary Claims Data API (BCDA) can give organizations a six- to eight-week advantage over monthly claim loads like the Claim and Claim Line Feed (CCLF) files. Not only can it help organizations arrive at what happened recently in clinical care, but it also can predict financial outcomes faster. This is important as organizations pivot mid-year to adjust to changing utilization patterns and disrupters in their market.
- Discover variation in specialist practice patterns: In the latest Center for Medicare & Medicaid Innovation strategy refresh, CMS stated they will create payment and performance incentives in models, especially in total cost of care models, for specialty and primary care providers, to coordinate delivery of high-value care.
As of February 2024, MSSP and REACH accountable care organizations (ACOs) now receive "shadow bundles" data, highlighting costs among specialists and taking the first step for total cost of care models like ACOs to manage more high-cost specialty and episodic care using lessons learned from bundled payments and other models. The three types of files include episode-level files, quarterly summary reports and annual benchmark prices that will highlight where ACOs have opportunities to improve specialty engagement and performance.
However, specialty engagement should extend beyond managing referral patterns and move toward aligning cost with appropriateness of care. Using claims data and evidence-based practice patterns, an organization can engage specialists in care variation reduction that aligns with lower cost, high quality care that is specific to each specialty.
By benchmarking utilization and payer rates, developing a strong value proposition, and monitoring progress toward value-based goals with timely financial projections and specialty alignment, health systems can successfully navigate the transition to value-based care arrangements with payers. The strategies above showcase how Vizient providers can go beyond the traditional methods of claims data reporting to provide meaningful interventions for patient engagement and improve quality and cost of care.
If your value-based care data strategy needs assistance, the Vizient Value Transformation & Payer-Provider Alignment practice can assist with unlocking your potential and utilizing data in creative ways to illuminate and improve your value as a care partner.
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