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Helping Payers and Providers Take Value-Based Care Across the Finish Line

If there was ever any doubt, the last few years have proven that the race to achieve value-based care is a marathon, not a sprint.

The first stage was just gaining acceptance for the concept of changing the core structure of an entire industry. The second was putting the mechanisms in place, such as digitizing health data and developing highly precise predictive analytics, to begin the actual transition.

Those stages have largely been completed, which means we now have a much better idea of who the high-cost, high-risk members/patients are and the kind of care they need to reduce that risk/cost. That’s all good. But to get across the finish line, the healthcare sector needs to solve two more issues: who is going to deliver the additional required care, and who is going to pay for it?

Going beyond acute

In the old fee-for-service model, physicians and other clinicians provided care primarily to those with acute needs who came to their office or to the hospital, and payers reimbursed them for that work. Anything that happened outside of a typical care setting was left primarily to the member/patient. Consequently, things like scheduling follow-up appointments, going in for regular lab tests, and taking all medications as-prescribed often didn’t happen.

Essentially, the mantra was “If I don’t feel bad I must be doing alright.” This thinking led to a higher-than-necessary level of hospital utilization rates. It also resulted in more uncontrolled chronic conditions that were not addressed until the person experienced an acute episode. It was like stumbling with the finish line in sight – and then continually being sent back to a previous checkpoint.

Of course, that was acceptable to the financial leaders within healthcare because more services meant more money. Now that healthcare reimbursement is moving from encounters to episodic care, however, the need for change is apparent to all.

Breaking the cycle

Offering care coordination services to high-risk members/patients (and others who need it) has proven successful in creating a way out of that temporal loop. Rather than leaving it to members/patients to make their way alone through the many hills, potholes, and other challenges of the healthcare system, care coordinators are there to smooth the route.

Of course, care coordination is not without its own challenges. For example, it’s one thing to send reminders to a member/patient about an upcoming laboratory test; it’s another to know how to send that message in a way that will actually drive an action.

If the care coordinator sends an email to an address the member/patient rarely checks, “follow up” may be checked off the list but the notification may go unnoticed. But if the care coordinator has documented that the member/patient prefers texts – and has responded positively to them in the past – there is a far greater likelihood of the desired action taking place.

Another example is understanding the barriers the member/patient may face in terms of social determinants of health (SDoH). When that text message goes out, the member/patient may have every desire of going in for the laboratory test. But if he/she doesn’t have a way of getting to the location, the appointment will be missed.

This is where having the right expertise and technology can help drive care coordination to a higher level – and bring value-based-care across the finish line.

A well-designed care coordination protocol will begin by asking key questions that will lead to success, such as how the member/patient prefers to be contacted (and at what times). It will also search for the SDoH barriers they are facing, whether it’s something mechanical such as a lack of transportation or an inability to receive mail order medications in bulk due to a small mailbox in an apartment building, or a personal issue such as loneliness that can lead to depression and a lack of desire to follow a plan of care. Gaining a thorough understanding of the member/patient’s preferences and challenges from the beginning will inform plan of care design.

The care coordination protocol will also focus on understanding what motivates each member individually as well as the best way to engage them. Here, the learning curve can be shortened considerably through regular face-to-face contact rather than relying solely on impersonal electronic contacts. Think about the cool detachment of email versus the warmth of meeting and getting to know people in person.

Knowing the concerns that interest members – not just from what they are told by the members but also from observing the pictures in their homes or the way they light up when speaking about their grandchildren – creates guidance to help members become more vested in the outcome and the solution. Understanding how to elicit this information and nurture that progress in moving toward healthier behaviors is essential for a more effective service model – and for the skillset of a care coordinator.

Having the right technology also plays a role in plan of care design, because it can offer an evidence-based head start. Using artificial intelligence and predictive analytics, the technology can create a recommended plan of care that is delivered to the care coordinator, physician, and other clinicians.

The data-driven plan will be based on members/patients with similar conditions, demographics, SDoH challenges, and outcome goals. It can then be adjusted as-needed to fit the particular circumstances of the member/patient. It may not be perfect, but having a starting point will save time and help with another major contributor to value-based care – minimizing variations. It will also greatly increase the chances of the plan of care succeeding.

Becoming self-sustaining

The other question that comes up with any new program in healthcare is “who will pay for all of this wonderfulness?” Especially given the financial pressures most payers and providers are already facing.

That’s the beauty of this type of precision, value-based care coordination. It essentially pays for itself, especially for capitated members/patients such as those in accountable care organizations (ACOs), employer-sponsored programs, and Medicare where risk adjustment factors (RAFs) come into play.

By doing a better job of keeping members/patients healthier, their overall costs are reduced, enabling payers and providers to take the money that was going into expensive care and re-direct it into care coordination and other wellness programs.

Build or buy

Once you’re sold on the value of this type of data-driven care coordination, the final question becomes whether to build the capabilities in-house or partner with an organization that offers these types of services. That should be an easy decision.

Building the capabilities alone can take months, or even more than a year. Then once they’re in place you still must acquire the experience and expertise to take full advantage of them. It could take two years or more before your program begins to pay dividends.

By partnering with an organization that already has the technology and expertise in place, you can bypass all of that and get your program launched within weeks of the decision to proceed. You’ll be able to affect more members/patients faster, and start seeing the ROI more quickly as well. In addition, as new technologies and methodologies become available you won’t be stuck with your old programs due to a high sunk cost. The partner will handle all of that, leaving you to simply reap the benefits.

The final kick

While the finish line for achieving value-based care may still be off in the distance, it is coming into sight. What’s needed now is a better way to ensure that those members/patients who need high-touch care get it -whatever that entails.

Better, more tailored, data-driven care coordination is demonstrating itself as the extra kick payers and providers need to get to (and across) the finish line. If you’re not ready to launch a program today, you may want to find a partner who is.

Where are you in your race for value-based care? Do you feel ready to offer the type of care coordination that accelerates better outcomes? If not, what elements are missing? Click here to share your thoughts. 

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