While it's too early to tell, many industry leaders speculate that the financial impacts of the COVID-19 pandemic will push providers to take a more serious look at value-based care models.
And as interest in those models grow, data analytics startup Apervita has rolled out new technology tools to help providers and payers better manage the complex contract arrangements of these payment models.
The solution for providers and payers, called QPay, is designed to improve transparency in value-based care contracts, the company told Fierce Healthcare.
Shared-risk payment models require the ability to maintain and manage a growing number of contract terms. Key terms that figure into the final reconciliation of value-based contracts can include cost targets, excluded services such as behavioral health services or pharmacy claims and stop-loss methodology.
There was a strong surge of interest in moving to value-based care models at the outset of the pandemic when providers saw volumes flag and financial pressures grow amid stay-at-home orders, according to UnitedHealth Group CEO David Wichmann while speaking at a conference last month.
Federal official Seema Verma, who heads the Centers for Medicare & Medicaid Services (CMS), also said Tuesday during the HTLH 2020 virtual conference that the agency "isn't shying away from value-based care" but hinted that CMS wants providers to take on financial risk at a faster pace.
But there is often friction between providers and payers due to the lack of understanding around the complexity of contract terms and this can lead to disputes over reimbursements, according to Stephanie Graham, Apervita vice president of payer innovation.
"This platform helps to summarize those key contract terms and offers performance insights and guidance for anticipating the final settlement results," Graham told Fierce Healthcare. "It offers a 'single source of truth' for managing ever-changing physician rosters and value-based contact terms."
Historically, adoption of value-based care models has been hampered by complex and conflicting interests and structures in the industry as well as IT infrastructural challenges and increasing administrative complexity, according to industry leaders.
Graham agrees with current industry feedback that COVID-19 is driving increased interest in value-based contract arrangements.
"There has been a lot of interest in value-based care models in the past few years, but the intimidation factor that these contracts might be too complex to figure out and a reluctancy to take on that risk has held some providers back," Graham said. "I do think the pandemic has driven more interest because of the lack of revenue for those providers on fee-for-service models. Providers have conceptually understood the value and need to shift to value but they weren't ready to make that shift."
Chicago-based Apertiva launched its QPay solution in August to help solve a major pain point for payers and providers: viewing and managing provider rosters.
Being able to capture the relationship between a physician or provider practice and a health system is critical to ensure the appropriate health system is held accountable for the patients and is properly reimbursed. Physicians can move in and out of health systems during a contract period, according to the company.
Having a reliable way to track this significantly reduces the administrative burden for both payers and providers. It also eliminates the question of whether the right physicians were measured and paid based on their relationship to a health system at a given point in time.
The cloud-based platform also enables providers and payers to run performance analytics on value-based contracts to understand the anticipated financial results.
Apertiva added new tools to the platform that captures the contract terms and applies them to the performance analytics, offering actionable insights for a provider to act upon, which can influence and ultimately change how much providers get paid based on those contracts.
By improving how organizations manage these contracts, it builds payer-provider collaboration, leading to financial success for both parties, according to the company.
“Our value optimization solutions remove the black box effect from value-based contracts,” said Kevin Hutchinson, Apervita CEO in a statement. “It removes difficult operational barriers that payers and providers wrestle with daily. Understanding the key terms, methods and contractual targets and knowing which providers are at risk with the provider roster creates a single solution, enabling all parties to focus less on administrative tasks and more on improving healthcare.”
Apervita started in 2012 as a developer of a collaboration platform for value-based healthcare. The startup focuses its efforts on helping hospitals and insurers share data and considers data security and privacy to be mission-critical to its business.
Hutchinson is the founding CEO and former president of Surescripts, a health IT company that supports electronic prescriptions. Surescripts built an infrastructure connecting pharmaceutical companies, pharmacy benefit managers, physicians' offices, hospitals, and laboratories.
In the same vein, Apervita has focused on building an infrastructure to enable physician practices, hospitals and health plans to collaboratively track performance measures against value-based contracts.
The company now works with more than 2,500 hospitals in the U.S., manages 1.8 million lives, and conducts more than 10 billion value-based computations and insights for its clients every year.
The startup has raised $59 million to date, according to Crunchbase. Investors include Optum Ventures, Pritzker Group Venture Capital, Baird Capital, Math Ventures, Levy Family Partners, Illinois Venture and Wintrust.