Value-Based Care: Four Key Competencies for Success

This white paper reviews the evolution of value-based contracting, including the difficult lessons early clinically integrated systems learned, the new dynamics that drive value-based care success, and the key interventions that impact contracts. The paper also explains how, by leveraging a framework based on a thorough understanding of five population health management (PHM) competencies, health systems can drive effective clinical and financial outcomes across the value-based care continuum.

Understanding Value-Based Care with a Brief History of Clinical Integration

任何基于价值的治疗的讨论必须从理解临床整合实体的发展开始。20世纪90年代，美国司法部就临床整合的反垄断标准提出了具有里程碑意义的意见。今天，这一核心原则仍然存在:如果供应商网络创造了高度的相互依赖关系，并致力于控制成本和确保质量，这种安排可以满足联邦机构的反垄断审查。

In 2012, under theAffordable Care Act(ACA),CMSreleased the first applications for theMedicare Shared Savings Program(MSSP)，为临床整合提供了一个框架。The program’s emphasis on impacting quality and cost goals for a patient population assigned to an ACO became a dominant example of the abilities of previously unavailable claims data.

This first MSSP iteration showed a steep learning curve to use data effectively and to build successful interventions across the national market. Other contracts paced the transition more appropriately for clinically integrated entities. Value-based contracts that focused on paying for successes by measuring and improving quality dominated the early adoption.

TheHealth Care Payment and Learning Action Network(HCP-LAN)—a group of public, private, and non-profit organizations devoted to spreading value-based care initiatives—built a framework and defined APMs on a continuum; Figure 1 shows these definitions from category one (fee for service) to category four (population-based payment). In building the APM framework, HCP-LAN authors agreed that the objective of payment reform was to change national trends and move payments into categories three (APMs built on fee-for-service architecture) and four (population-based payment), per Figure 1.

由于MSSP下的转型强调通过新整合的网络测量和管理质量，为质量报告吸收数据需要大量的组织努力。重要的核心数据操作(如财务指标)被搁置一旁。Initially, two dominating competencies emerged among clinically integrated entities:

1. Establishing an effective governance that could lead the newly structured organization through challenging decisions to improve quality improvement and cost efficiencies
2. Clinically transforming away from siloed decisions to integrated care across the continuum.

However, without a true sense of urgency to take on risk (due to minimal, publicly validated cost-reduction interventions), the general mandate for the first clinically integrated entities became clear: to understand how to measure and manage quality across a newly organized group of providers. Under this mandate, clinically integrated entities prioritized quality reporting objectives over other key considerations, including data ingestion, data activation, and cost reduction interventions.

To succeed in at-risk contracts, however, organizations must not overlook any competency. They must instead constantly review and optimize the five core PHM competencies through a continual review and improvement process.

Optimizing the Five Key Competencies

To achieve PHM transformation, organizations must create a governance structure that uses an effective framework based on five competencies:

Competency #1: Governance that Educates, Engages, and Energizes

Figure 2 shows Health Catalyst’s framework for PHM success, fromdata并分析向付费和护理转型。这个框架的初步步骤是确定组织范围内的治理，以监督向基于价值的关怀的转变。对临床医生和利益相关者进行教育、参与和激励的治理过程是建立强大文化的关键一步，这种文化可以长期支持困难的财务、临床和以患者为中心的决策。

As organizations establish governance, they typically form committees with charters that include authority and responsibility, definitions of success, and participation standards. This is a critical step, as many operational teams will work together for the first time, and/or in new roles, in value-based care transformation—often to impact metrics that are new to them.

在这一步中，成功的捷径是将正确的人引入运营团队。一般来说，临床整合组织寻求的是能够影响干预措施的精益团队。Several roles are critical for engaging executives and spreading quality and cost reduction initiatives:

• Data stewards and data analysts—These distinct resources need to interact with the right data (claims, clinical, and financial) and disseminate that information to the right end users, including leadership and frontline clinicians. Data stewards control the data, while data analysts identify intelligence in it.
• 护理管理领导——无论组织采取何种形式的护理管理临床干预，都必须有一个领导，在与执行领导沟通的同时促进程序性目标的实现。
• Project management resources—Many clinically integrated entities and ACOs spend substantial dollars on individuals trained in provider support services. These individuals work with multiple clinics to manage deadlines and facilitate success on key contract elements, such as hierarchical coding category (HCC) documentation, patient/physician usage (sometimes known as leakage), and weekly clinical huddles.
• Cross-departmental facilitator—This jack-of-all-trades role helps coordinate organizationwide contract-based elements. For example, the facilitator may lead a cross-departmental effort to incorporate non-billable CPT-II quality tracking codes for data collection when submitting billable data (these codes have become increasingly popular to help clinical teams capture completed work supporting the claims-based quality measures in Medicare payment models).

Competency #2: Data Transformation that Addresses Clinical, Financial, and Operational Questions

As the governance structure evolves, organizations must take a data-driven approach to answer clinical, financial, and operational questions. To gather insights over time, health systems must identify a variety of sources that can produce intelligence and drive interventions across the clinically integrated entity’s needs. These interventions should not wholly depend on claims data.

For example, organizations often use cost movement (achieving lower total cost of care across a population by shifting the costs to a less-intensive resource) as an initial intervention based on available data. To reduce costs, claims data needs to be integrated with additional sources. Today’s clinically integrated organizations have begun using additional data sources to identify interventions that impact the actual costs necessary to deliver care to their patients.

Organizations drive intelligence by ingesting the following data:

1. 索赔数据索赔数据提供了一个横跨患者群体连续体的现象级视图，使组织能够看到以前不可见的护理提供领域的患者使用率。
2. Clinical data—Connecting claims data with the right clinical data (e.g., daily patient statistics and admit-discharge-transfer feeds) from multiple settings provides accurate patient-specific data. To effectively impact cost reduction opportunities, clinical leads and care management teams need as close as possible to real-time patient lists describing patients at-risk for inpatient, readmission, or high-cost scenarios.
3. Costing data—In addition to claims and clinical data, costing data is the third leg of the data stool. Many value-based contracts rely on reviewing key utilization statistics and per member per month (PMPM) spend. Knowing the actual cost to produce the care delivered, however, remains an undervalued endeavor.

To truly measure the cost of a healthcare encounter, organizations need all three of the above data sources. Next-generation costing products, such as the Health Catalyst® CORUS®, facilitate this understanding by helping organizations more comprehensively define the true cost of the services they provide and those services’ impacts on patient outcomes. Ingesting all of these data sources into a single source (such as a data operating system) creates an infrastructure that provides the most value upfront and long-term.

Competency #3: Analytic Transformation that Aligns Information and Identifies Populations

With the right governance structure and analytic backbone, clinically integrated entities are ready to identify appropriate contracts, patient populations, and interventions. During this stage, various teams (as defined under the governance structure) will answer critical questions to drive interventions to the appropriate patients. By incorporating disparate data sources into a common structure, clinically integrated entities are building intelligence that allows them to succeed in appropriate financial and clinical transformation initiatives.

Figure 3 shows how an operational vehicle (e.g., a clinical quality committee) can aggregate information and use an analytic tool to identify a population for a specific care management intervention.

Competency #4: Payment Transformation that Drives Long-term Sustainability

签订有风险的合同(而不是单方面的协议)对于获得适当的财政收入来维持长期的基于价值的合同是必要的。组织必须寻求一种合同组合，在履行合同义务的同时，适当调整临床医生影响选定人群的能力。

一些基于价值的合同侧重于利用特定的患者群体来降低护理的总成本。MSSP根据评估和管理规范的组合分配归因，这些规范可能无意中将患者归为专家或非战略性实体(例如，邻近的医生，其税务识别号没有加入ACO)。

Value-based contracts for specialists are increasingly available. Through a clinically integrated network, hospitals can structure quality and efficiency improvement programs that pay fair-market value for quality-based cost reduction initiatives. Bundled payments are emerging as a valuable source of distribution payments for specialists. For example, the top 25 performing participants in the first year of theComprehensive Joint Replacementinitiative anticipate receiving over $1,000 per episode after final program reconciliation is complete. By adopting such initiatives, broader, clinically integrated entities can mitigate the potential for specialist disenfranchisement under value-based care.

Competency #5: Care Transformation as a Key Intervention in Value-Based Contracts

护理改革是基于价值的合同中节约内部成本的一个关键措施。虽然精简方法以提高全系统质量仍然是临床整合的重要组成部分，但这可能是一项高成本、高努力的工作。通过优化护理管理方案，护理转型帮助组织减少临床差异，提高整个网络的成本节约。

Partners Healthcare, a large, integrated healthcare delivery system, created itsIntegrated Care Management Program(iCMP)最初作为一种特定于医疗保险的干预。合作伙伴通过检查2012年至2014年的医疗保险患者数据来验证其模型，并审查了每个受益人每月的总成本和其他关键指标。The overall Medicare spending of patients enrolled in the Partners iCMP dropped by $101 PMPM (or $87 more than the cost decline for patients inside Partners’ ACO program), according to a2017 study.

减少临床变异的措施也被证明是有效的降低成本的方法。For example, when a large integrated delivery system aimed toreduce unwanted clinical variation, it deployed an analytics platform to aggregate and analyze patient outcomes data. As a result, the organization reduced cost per patient by $2,401 and length of stay by more than eight days. These achievements translated to projected millions in savings in subsequent years.

Control the Levers—Identify Interventions Per Initiative and Scale

Generally, intervention design occurs alongside payment and care transformation. Depending on the data, clinically integrated entities identify the right value-based contract that meets their care transformation goals where they are and that they can impact with appropriate interventions.

The next step is to determine which intervention to implement first. To do so, organizations must answer key questions about how various initiatives may impact specific value-based contracts:

• What are the cost drivers?
• 组织能否分析成本变动?
• What are the costs across the continuum?
• How much is driven by network management?
• How much is driven by clinical documentation?

然后，组织必须决定将哪种类型的干预措施以及何时引入市场。This step requires a review of important characteristics making up contracts, with many of those characteristics remaining consistent across payer entities:

• Benchmark cost—Benchmarks are impacted by historical information of the clinicians inside the clinically integrated entity. To assist in evaluating how to attack network dynamics per benchmark, identify physicians’ TIN, the historical billing information per physician inside the entity, and whether attributed will be retrospective versus prospective.
• Currency components—Currency components are areas of the contract that directly impact total potential to be earned. For example, some value-based contracts place PMPM dollars on meeting chronic care program utilization targets. This element complements an upside-only initiative that has a high opportunity to impact coordination costs and patient’s use of preferred health systems and clinicians.
• Efficiency-based measure opportunities—Organizations need to negotiate or seek contracts with a favorable medical loss ratio, risk adjustment factor target, and efficiency-based measure opportunities. For example, after piloting a specific chronic care program, the organization may seek pharmacy management and utilization reviews as additional tools for cost reduction. The organization builds a more comprehensive complex care management program on top of their chronic care initiative’s lessons learned to impact a new Medicaid specific value-contract.

Organizations need to identify the intervention’s expected time to value, the financial impact, which patient populations it applies to, and how will to operationalize it. Next, health systems will place these interventions into an operational plan to address their ability for scale across multiplevalue-based contracts. This can help identify the appropriate time to move into a risk-threshold that optimally straddles both fee-for-value and fee-for-service payments.

The Continuing Journey to Better Quality at Lower Cost

The journey to value-base care is ongoing yet delivers increasingly better-quality care to patients at a lower cost along the way. Organizations can structure their journeys to value-based care by continually evaluating their performance in relation to their value-based care competencies.

By understanding their current progress toward value-based contracting and factoring in local market needs, health systems can begin to identify strengths, as well as gaps, for effectively managing upcoming value-based care initiatives. Using a competency-based approach, and by leveraging purposeful interventions, organizations can create a framework for sustainable value-based contracting success.

Additional Reading

Would you like to learn more about this topic? Here are some articles we suggest:

1. The Key to Transitioning from Fee-for-Service to Value-Based Reimbursement
2. Care Management Solutions Improve Sprint to Value