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The Road to Payer-Provider Convergence is Paved with Advanced Analytics

Mark A. Caron, CHCIO, FACHE, CEO, Geneia

Notwithstanding the Centers for Medicare and Medicaid Services (CMS) decision in August to cancel three mandatory bundled payment programs and roll back a fourth, I concur with the views of many healthcare leaders that value-based care is here to stay as is the model’s corollary payer-provider convergence.

Payers have moved aggressively to create value-based contracts with their provider networks. Aetna, Anthem and UnitedHealth all report approximately 50 percent of reimbursements are via value-based care models, and Aetna has pledged to grow it to 75-80 percent by 2020.

The shift to value-based care isn’t limited to national payers. A plan with which I am quite familiar, Capital BlueCross, launched its first accountable care arrangement in 2011. Today, nearly 3,000 providers and 360,000 members participate in the payer’s performance based models.

Capital BlueCross has reported significant success with its value-based partnerships. Data for a recent 12-month period show Capital’s accountable care providers are outperforming their peers:

  • Acute inpatient hospital admissions are 4.7 percent lower for employer group customers and 7.2 percent lower for Medicare plan customers.
  • Hospital readmissions are 8 percent lower for employer group customers and 14.8 percent lower for Medicare plan customers.
  • Emergency department visits are more than 8 percent lower for employer group and Medicare plan customers.

From December 2015 to November 2016, the company’s accountable care partners markedly outperformed their fee-for-service peers in 19 of 25 tracked Healthcare Effectiveness Data and Information Set (HEDIS®) measures, including breast, cervical and colorectal cancer screenings.

Market & Government forces Driving Alignment and Convergence of Payers and Providers

Undoubtedly, there are many market and government forces driving convergence. Some of the most influential are:

  • Health cost increases: Per capita expenditures are projected to grow from $10,345 in 2016 to $16,032 in 2025, an average annual growth rate of 5 percent.
  • Silver Tsunami: Medicare enrollment is expected to grow by more than 30 percent in the coming decade, and the number of seniors will increase from 57 million today to more t han 80 million by 2036.
  • Quality emphasis: Quality measurement in the form of HEDIS® Medicare Stars, MACRA and MIPS increasingly demands continuous improvement of payers and their network providers.

Equally important, payers’ primary customers – employers – are increasingly looking to value based care and narrow networks to achieve their quality and cost goals. AON reports half of employers are considering “high performance networks to provide simplicity of choice and consistency of care for plan members.”

Technology and Analytics Enable Collaboration and Convergence

The availability of advanced analytics and the associated timely, prioritized patient and population insights has accelerated the alignment and convergence of payers and providers and the early success of value-based care arrangements.

It is worth noting that the use of shared analytics platform is critical to Capital BlueCross’ success. Capital provides all of its accountable care partners with Geneia’s Theon® advanced analytics tool. Key staff from Capital and network providers work in a shared cost and quality improvement platform, one that provides all users with:

  • Comprehensive, stratified views of members and member populations
  • Timely, prioritized care and intervention recommendations
  • Simplified and real-time care gap identification and closure

Just as importantly, providers can pay an additional fee to use the Theon® platform to manage all of their value-based contracts regardless of the payer.

Population Health Experts

In the six years since Capital BlueCross created its first value-based relationship, it found technology and analytics are critically important, but in many cases, not enough to build the kind of collaborative relationships to deliver year-over-year improvements in the cost and quality of member health care.

That’s why Capital has deployed a Geneia population health expert to each of its value-based partnerships. This clinician is the key point of contact between the payer’s traditional case and disease managers and the provider’s office. They work collaboratively and consistently with physician leadership to dive deep into the analytical insights found in the Theon® platform and develop plans of action to address variations across members, providers and facilities.

Our population health experts are directly responsible for coordinating the most appropriate care and services for Capital’s members and drive improved health outcomes. Indirectly, they are on the frontlines of increasing alignment and collaboration between the health plan and its network of providers.

ACOs and value-based care contracts are the important first step in payer-provider convergence. It’s my belief that the next steps are the payer helping its provider network to achieve success in their value-based arrangements by providing technology and analytics along with population health experts to help prioritize interventions and lighten the load for providers.

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Geneia LLC is an analytic solutions and services company that helps our clients improve outcomes, lower costs and restore the Joy of Medicine to physician practice. To learn more, visit Geneia.com.

This article was created in collaboration with the sponsoring company and our sales and marketing team. The editorial team does not contribute.
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