A Paradigm Shift
To transition to true value-based care, the entire industry will need to collect, understand, and use data in ways different from anything it has done before.
A provider practicing in the old fee-for-service environment asks: How can I get reimbursed for my services? The answer is to use all available options without necessarily paying attention to the outcome. Not surprisingly, the result of this fee-for-service model is low-quality care.
A provider who adheres to digital quality measurement asks: What treatments for other patients with this condition lead to the best outcomes? As the market continues to evolve, providers will follow treatment plans backed by clinical measurements of quality. The best course of action will be clear to everyone—the practitioner, the health plan, and the patient/member.
A Two-Way Street
In a value-based healthcare environment, information flows to and from providers and health plans: Providers with access to [de-personalized or hashed] anonymous digital records and current clinical data will be motivated to share information with healthcare partners who in turn will reward them for providing patients with the best care possible. This exchange will lead to more contracts based on digital measures of performance, and simultaneously to greater clinical insight. Health plans and regulatory institutions will share real-time data that help other providers, healthcare plans, and members of health plans.
A Cooperative Approach
The paradigm shifts toward a model of risk and reward that drives better outcomes and lower costs results in better healthcare. When providers are rewarded only for better performance, they don’t go around in circles about which actions to take. This saves money. Doctors don’t order from a treatment menu based solely on successful claims. Patients receive clinically backed care that helps them feel better, so they have more confidence in their providers. They see more value in their healthcare plan because quality healthcare is more affordable healthcare. Providers, in turn, experience more fulfilling relationships with their patients, and healthcare plans gain prestige.
Proactive versus Reactive Roles
Armed with digital quality measurements, providers and health plans have more control, and so tend to be proactive rather than reactive. If a provider knows they’ll be rewarded for following procedures that align with a patient’s condition, they’re bound to follow that clinically driven protocol. Value-based medicine backed by digital measurements of quality reduce the friction between health plans and providers because providers aren’t flying blind—they know they’ll be rewarded for taking actions that produce good results.
Improved Network Performance
To improve their health plans’ performance industry executives are developing new care strategies based on digital reporting. For instance, they might group individuals according to such factors as age and/or health condition. Such an approach has proven more effective than global approaches and brings about better outcomes, not only for providers and patients but for the networks themselves.
Nascent technologies such as artificial intelligence, natural language programing (NLP), and machine learning (in which NLP is fine-tuned to a particular environment) directly support the move to digital quality measurement.
Technology companies will continue to innovate for the industry. Astrata, for instance, is focusing on several integrative technologies: NLP, Clinical Quality Language (CQL), and Fast Healthcare Interoperability Resources (FHIR), such as Quality Improvement Core (QI-Core) applications.
Currently, CMS and the Affordable Care Act (ACA) are starting to move from a reactive, claims- and process-based system to a proactive, clinically sound, evidence-based system built on whole populations.