IT’s Role in Supporting and Enabling Value-based Care

Aired on: Wed, February 16, 2022

314e at HLS Symposium 2022 | 314e Corporation

In this webinar, Dr. Siv shares his expert insights on how value-based care can improve overall patient outcomes and control medical costs with the help of Information technology. The session was well attended and ended with an engaging Q&A session.

The key topics discussed during the session include:

  • The processes that a Value-Based Care effort is comprised of
  • The parts of Value-Based Care that need provider-IT enablement
  • Best practices for IT to follow in order to make a VBC effort in their organization successful
Dr. Siv Raman
**Speaker: Dr. Siv Raman**
Chief Product Officer at 314e
With 18 years of Fortune 50 leadership experience in Health IT and analytics. He is an industry expert on the healthcare payer & provider space with focus on analytics, informatics, big data innovation & population health management.

Here is the transcript of the webinar

Aaron Waggoner 0:04
Hello and good afternoon. My name is Aaron Waggoner, Foundation Specialist with Corporate Member Services for Chime. And it's my pleasure to welcome you to today's webinar: IT''s role in supporting and enabling value-based care. Before we get started with the presentation, I'm going to cover just a few technical details. The q&a area is located on your screen option bar; This will allow you to ask questions during today's presentation. To ask a question, type your message into the q&a chat box and press the send key. The speaker will try and answer as many questions as possible at the end of the presentation. If you're having difficulty listening to the live audio stream through your computer speakers, teleconferencing is available. To display the teleconference instructions, click on the communicate menu to view your audio options. Also, by attending today's session, you may earn up to one continuing education credit. Please be sure to visit the Chime website for more details. We also ask that you please take a few moments to complete the evaluation that will automatically pop up in your web browser at the end of the session. Your feedback is valuable for all of our future programming. And just a quick reminder all registrants for this event will receive a link to the session recording following the webinar. With that said, I am pleased to introduce our speaker for today's session. With us today is Dr. Siv Raman, Chief Products and Analytics Officer with 314e Corporation. Siv, thank you so much for joining us today; I'm going to turn things over to you.

Dr. Siv Raman 1:33
Thank you for the introduction, Aaron. So today's webinar, I'm going to be covering information technology's role in enabling value-based care; and my focus is on the provider's side of IT because on the payer and the health insurance plan side, a lot of these processees have been enabled by it for decades. But now that the value-based care efforts are involving providers, and there's also payer-provider alignment happening, you know, provider-IT has to do things to support these VBC initiatives in their organizations. Move on. So this is just about my company 314e. We were founded in 2004; we are a health IT shop headquartered in Silicon Valley. We have both service and product offerings. In the service offerings, we have electronic health record implementation, e-learning, revenue cycle management and other services. We have products for data archival, digital adoption, health data analytics, and platforms and interface engines. And here's a snapshot of our customers worldwide. And nationwide, as well as industry affiliations, independent ratings, including those from KLAS and our technology partnerships. So I'm starting a presentation on value-based care by describing what is known as the triple aim of healthcare and I'm doing that for a reason. So the triple aim of healthcare, this was an aspirational goal first proposed by the Institute of Healthcare Improvement, and there are three parts to it, patient experience, which includes quality and self-satisfaction, and that specifically also includes access to care. The second part of the aim is improving the health of populations. And lastly, reducing the purpose and cost of health care. Now, in the US, the patient experience, especially regarding access, improved a lot because of the Affordable Care Act, you know, with the expansion of Medicaid and also the exchanges, providing health insurance coverage to more of the population. I would say that the access part has been dealt with successfully. However, if you look at the other parts of the triple aim, improving the health of populations and certainly reducing the cost of health care. Those are not goals or aims that have been met. And so that's what value-based care is all about. It's a healthcare payment methodology that ties the reimbursement to the quality and efficiency of clinical services or healthcare services as a whole, right. So the easy way to understand value-based care is to think of it as care that works towards achieving the triple aim. And there's another term you will come across, which is population health management. And that pretty much includes all the processees that are involved in providing value-based care. Now, value-based care goes hand in hand with value-based reimbursement, because the idea being that you are reimbursing for value; value being the achievement of better outcomes, better health care services at a good price, right. So that's the reason why, when you talk about value-based care, the way it is realized in a contract between a payer and a provider is through some sort of value-based Reimbursement Arrangement.

Dr. Siv Raman 6:13
And when you think about value-based reimbursement and value-based care, there's usually a continuum. I've listed a lot of these here for, starting from pay for performance to patient-centered medical homes right up to what are now called provider-sponsored health plans because these are providers, health systems, that are creating their own health plans. And, you know, kind of assuming the role of a payer as well. And the real way to differentiate various types of value-based care offerings, is by understanding the financial risks that the providers are bearing, right, because traditionally, in a fee-for-service system, which is what we have, in healthcare, for the most part in the US, there is no real financial risk to providers in terms of the medical costs, right, the medical costs are borne by the members are the patients themselves and by the health insurance company or the health insurance plan that is insuring them. In many cases, of course, they're borne by the employers, especially in self-insured plans. But the financial risk to providers in a traditional fee-for-service system where you get paid for services delivered is minimal. But in a value-based care arrangement, you have various levels of risk that are being transferred from the payer to the provider. And so you can categorize that as upside risks and downside risks. So upside means that the provider is usually promised some sort of bonus if they are able to meet medical cost reduction or medical cost containment targets. And if they don't hit those targets, they might lose that bonus. So that means the risk is only on the upside, right, you might lose a bonus, but you're not going to lose the revenue or the reimbursement that you're getting today by billing for those services. So pay for performance, patient-centered medical homes, as well as shared savings, these types of arrangements between payers and providers are upside-only risks because they usually don't involve any medical cost risk to the provider. Now starting with bundled payments, that's when we get into the area of the risk being borne by the provider for medical costs. And that's why it's called downside risk, which means that to some extent, the provider is on the hook if the care targets or the sorry, the monetary targets for care are exceeded. Right. Now, these targets are usually laid out in the contract between the payer and the provider in terms of some sort of per member per month numbers, right. So there might be an effort to keep the yearly PMPM to less than, let's say $850 pmpm. So and so those targets, if those targets are not met in a downside risk model, the provider is losing money. And that is usually something that providers are not used to. Right. So that's something that payers have been very used to dealing with medical costs and medical expenses. But downside risk for providers is something new. And for the most part, they have been reluctant to assume it. Right. So from bundled payments to shared risk to capitation, which means folders for provider they have to, they're given a capitated amount per member. And they have to provide all the care that that member needs within that dollar amount. And finally, provider-sponsored health plans absolutely mean that the provider is taking on a huge amount of financial risk for medical costs.

Dr. Siv Raman 10:57
So when you're talking about any sort of …, now, also, there's, you know, there are, I didn't mention something here, which is an accountable care organization, because I'm not trying to describe all the types of value-based care arrangements. But somewhere in the shared risk area is also this concept of ACOs, or accountable care organizations, where a provider or a set of providers come together to take care of a population of patients and members. And the contract is with a payer that is insuring those members, but some of the financial risk is transferred to the provider groups as well. So there are six main parts of population health management; now I adapted this from something that was created about seven years back by a company named z omega. There are various formulations of this; there's five parts to or five pillars of population health management, and there are some people who talk about four parts. But for the purpose of this presentation and my talk here, I've adapted this to say that there are six main parts of population health management. So there's program design, contracting, and the setup, which is usually not something that information technology is deeply involved in. So that would be the provider side and the payer side network contracting people getting together to figure out a program design identifying the member population that is going to be under this contract, what are the milestones, the targets, what are the financial incentives, etc. From two through five, those are the four areas in which information technology has to be as provider side information technology has to be deeply involved in order to make value-based care arrangement a success, data integration and management, analytics and insights, care management and coordination and member and patient engagement.

Dr. Siv Raman 13:36
Number six, the physician engagement that is not something that usually falls under the purview of information technology, right. So, information technology has a role in it supporting all these other four efforts or parts of population health management, and there are some best practices to follow because these are things that care-IT has been doing for years, but provider-IT when they asked to support a value-based care effort, might sometimes be a little bit confused about where to start.

Dr. Siv Raman 14:27
Okay. So the first one is data management and integration. So this involves bringing in all the types of data that you will need to track and generate analytics from as part of that value-based reimbursement contract. And obviously, the EMR clinical data is something that the providers already have, but they do need to accommodate these health claims streams that come in from the payer, because ultimately the value-based reimbursement contract is about managing financial risks, in addition to clinical risk. There's also care management data, social determinants of health data, patient-reported data. Many of these types of data are foreign to providers at this point, right? They might have dealt with clinical data and claims data. But a lot of the other types of data to support a value-based care effort effectively, are not things that have been dealt with by the provider technology organizations. Now, what I would suggest in this case, is that it makes sense in terms of best practices, to have a dedicated health data platform to support this value-based care effort because you might think that you could get by with your existing warehouse or data effort. But when all of these new types of data have to be accommodated and not just stored, they have to be made available for analytics. That's when your existing health data platform might not be able to support the scaling that is required. Obviously, the data platform should accommodate multiple types of data from various sources, you need to accommodate batch and streaming data, because most of the data that you're going to be processing is batch data that can be loaded, maybe once a week. That includes claims, for example. But then there are data on let's say, admissions or patient referrals and things like that, that come in, that need to be acted on much faster than is possible with a batch load. So you need to have a platform that accommodates batch and streaming healthcare data. The platform should also directly enable analytics and other use cases, it's a good idea to have the data stored in some industry standards for data representation. And then you need to make sure that the business use cases for the data are served up. So the key takeaway then is you need to manage your data at scale, and directly enable analytics. The second part of population health management, at least the technology support for population health management comes from the analytics and insights. Because you have a health data platform, you're bringing all these data in, the reason you're bringing that data in is to generate insights about your member population, those insights that tell you where you're going to focus your efforts in order to improve the health of populations, close care gaps, and reduce medical costs. So if you look at the analytics component of a health data platform, it needs to support various types of Reporting Analytics, and even, you know, newer modalities like artificial intelligence and predictive models. So business intelligence and clinical dashboards and financial dashboards. They're all traditionally

Dr. Siv Raman 19:07
traditional modes of analytics delivery, that need to be supported for the data that we are processing. But you also have to look at advanced visualization, risk identification, and stratification. Now, that's something that's not commonly done at providers, because risk identification and stratification involves identifying the members or patients that are most likely to drive the financial risk. Right…? So people who are likely to be high-cost claimants, who are likely to have hospitalizations, adverse events, and other situations that will lead to a huge healthcare expenditure. And it usually also comes with the fact that the person is lowering their healthcare standard, and they're at a more unhealthy space or place. And that's why their financial risk is higher than the strategy, the stratification then is to stratify these patients by risk, and by clinical and financial risk. So those processes have to be put in place as part of the analytics that your provider organization will need to process. Predictive models are also something that are highly valuable in a value-based care setting because what you need to be able to do is identify which patients are likely to have what sorts of adverse events, you're also wanting to find out which members or patients can be, you can intervene on them to prevent the adverse event or the bad health care outcome from happening. And so the aim is to predict and then try to ward off the bad medical event from happening because that's the way you can, you know, keep the population healthier, and control medical expenses. So in terms of best practices for analytics, you know, again, as I said before, the health data platform should directly enable Analytics, you don't want a health data platform that just stores the data. And then your analytics are being worked on in a siloed manner, on your analysts, desktops, and laptops, right. So you want the platforms to directly enable your analytics so that, that can be delivered real-time to the people who would utilize them to intervene. Now, in addition to descriptive analytics, predictive and prescriptive analytics should absolutely be utilized. And I specifically talked about risk identification and stratification and AI ML models for clinical and financial risks. And then there is a whole new class of predictive analytics that utilizes non-healthcare data, right? So especially the buzzword is now about social determinants of health. So these are things or factors in the environment, or in the social structure of specific members, that drives good or bad outcomes, health care outcomes. And so it's not enough to just figure out based on the clinical data and the associated data, how these patients are likely to have outcomes. But you also want to be able to use the other social determinants of health data in your models and in your identification and stratification. So again, the key takeaway from the analytic side is all types of analytics are required. Descriptive, predictive, and absolutely prescriptive, which describes or identifies the actions that the care team needs to take to prevent a bad outcome, a bad medical outcome from happening. The next part of population health management is care management and coordination. So again, this is something that payers have been doing for years. But it is mostly new to the provider world.

Dr. Siv Raman 24:12
You know, there are care management and care coordination efforts at hospitals, but they're not focused solely on reducing medical expenses. So, in terms of care management, you have obviously case management, disease management, chronic case management, the role of healthcare navigators is coming to the fore nowadays because these are people who can help patients and members navigate the healthcare system and therefore, get the right care the right medication, and get the right screenings and generally adhere to a proper care plan that can manage their condition. There, no there is a statistic out there that 5% of or less than 5% of patients drive 50% of the health care outcomes. So when you're identifying patients and members to target for care management and coordination efforts, you need to focus on the members that are likely to be the sickest and drive the biggest health care expenditures. And so that's where your analytics and insights needs to tie very closely with the care management and coordination. Care management systems themselves are usually managed by information technology. And they are also able to provide other outreach and care coordination activities, including behavioral health management, transitional care management, remote patient monitoring, utilization management, which is a very payer concept about managing inpatient utilization. But these are all things that are now required by provider-IT to look at because especially if you're in a value-based care contract that expects you to manage medical costs. So again, these are the best practices for care management and coordination. Now, analytics has to drive the care management and coordination efforts because you need to identify the specific member and patient population that you're going to focus on. Because you have only so many resources. And you cannot provide this care management and coordination to the whole population, you need to focus your efforts and those, the identified population is driven by Analytics. You should ideally have a care management system that acts as a hub that needs to be a change in mindset. You know, there's a bit of a payer mindset needed for these sets of activities. And lastly, a care team approach is critical because you know, it's not just the physician and the nurses who are involved in the care of the provision of health care. So you know, there's dietitians, social workers, there's remote monitoring nurses healthcare navigator, so there is a whole care team approach that is required. And the technology to enable this care team approach has to be put in place by information technology. So again, the key takeaway is that you require a multi-pronged care team-based strategy for effective care management and coordination. And lastly, there's member and patient engagement. So when you talk about member and patient engagement, what you're trying to achieve is an activated patient. So an activated patient is one who seizes the opportunity to improve their health and they're engaged in following their care plan. They are very adherent with their medications, they absolutely do everything that is required in terms of screening and treatment that is

Dr. Siv Raman 28:53
recommended or suggested to them by the healthcare provider. Right. So, and the reason we are talking about member and patient engagement is that it's obviously happening outside of the care setting. Because most of the health care costs are driven by chronic diseases, right, whether it's diabetes or heart disease, or musculoskeletal group of diseases, etc. And so the management of those diseases and conditions is not going to be done completely by, in the care setting, right. In the care setting, the patient is seen maybe once in two months or something like that, but it's what they do when they are not in the care setting when they are at home. That really matters in terms of what medical outcomes they get. And so the whole patient and member engagement effort has to be focused on reaching out to the patients where they live. And especially the patients who have these chronic diseases, and then helping them with health literacy, navigation, telehealth strategies, mobile strategies, and also obviously patient portal. So the member-patient engagement effort is not something that happens within the care setting, it happens outside of the care setting.

Dr. Siv Raman 30:32
So in terms of no best practices, you have to use a wide variety of engagement modalities. Now, not all engagement is digital. So it's not, there's only some parts that are technology-enabled, you might have an engagement strategy that involves sending a social worker out to check on a member at their home. That's not a digital part, but then a telemedicine visit might be something that is an alternative, which is a digital engagement effort. And then there's no one size fits all because different patients or different types of patients need different activation strategies. So that is the key takeaway, that the reason why you're using various types of engagement strategies to activate these patients, is because not everything works for everyone. So that is the end of my presentation. And I'm open to questions.

Aaron Waggoner 31:48
Great, thank you. We do have several questions that have come through. I will remind everyone if you do have a question, please be sure to type it into the q&a chat, and I will read it on your behalf. Okay, so the first question I had come through is, is IT responsible for the VBC implementation?

Dr. Siv Raman 32:08
So I would not say that information technology is responsible for the value-based care implementation in terms of the contract and the fact that but to make it a success, you need technology enablement, right, because when you're when your organization, the provider organization has entered into a value-based care contract, they need a whole set of activities to make sure that those financial and clinical targets are met. And that's where technology enablement is important.

Aaron Waggoner 32:54
Thank you. Also, the next question that came through is, since the aim of value-based care is to improve the population health, do you think value-based care initiatives at the national level or health care provider level?

Dr. Siv Raman 33:08
I'm only talking about the provider level, because at the national level, obviously, we have, you know, efforts by let's say the government, right. But when I'm talking about provider tech, IT enabling value-based care. It is specifically one value-based care arrangement between a payer and a provider. The payer might be the government like Medicare, Medicare has ACO programs. But I'm not talking about the national level, even though that's a separate effort going on at the national level.

Aaron Waggoner 33:50
Great, thank you. So the next question I have is, what is the best way to integrate the data needed for this value-based care?

Dr. Siv Raman 34:01
That's a really good question. Because, you know, when you're, when you're trying to integrate all these disparate types of data from various sources, the first challenge you run into, is that you know, you run out of scale. And you also find it problematic to accommodate these data, these new types of data in your existing systems are, you know, warehouses or wherever. So, the best strategy is to have a new dedicated health data platform that can accommodate all these new types of data, and then store them in industry-standard formats, and make them immediately available for analytics and other use cases.

Aaron Waggoner 35:03
Again, if you have a question, go ahead and pop it into the q&a chat. And I'll be sure to read it on your behalf. Roger, I did see your question. Yes, we will be sending out a copy of the PDF of the slide deck along with the recording. So the next question I have is, what is the best way to use these analytics to drive the patient activation?

Dr. Siv Raman 35:27
Right. So analytics to drive patient activation is, you know, the reason you're using analytics is you are firstly, identifying the patients who are most likely to drive your medical spend, right, and they're usually the most sick patients. And they usually have chronic diseases and multiple comorbidities. But then what you're trying to do there is, when you're using AI and ML and predictive models, you're trying to find this, the strategy that will work the best for a particular type of patient. So, you don't want to use a shotgun approach, your analytics has to be focused in understanding the particular patient, or member, and then you're tailoring your activation strategy based on that. So, some people might respond really well, too, for example, telemedicine, or mobile apps, others might actually need a health coach to visit them a few times a year. So these are all strategies that are based on the analytics that decide what sort of patient or member you're dealing with. And what's the most effective activation strategy for that member.

Aaron Waggoner 36:57
Thank you. So I'm coming up to my last question. So if there's any last-minute questions out there, please be sure to type it into the q&a chat. I will also remind you that the survey that pops up in your web browser, at the end of the session does allow you to type in comments or questions, please feel free to type anything in there as well. And I will make sure to get it to the 314e team. So the last question I had is, could you go more into what is identification and risk stratification?

Dr. Siv Raman 37:28
Okay. So the term comes from the payer, their health plan world, whereas part of their care management efforts, they have to focus on a set of patients because there are limited resources that you are applying in the care management and coordination world, you cannot do care management and coordination for the whole member population. So what you're trying to do there is, you're trying to identify the patients who are eligible for or, or would benefit the most from being enrolled in case management or disease management or specific chronic case management programs. Right. So, in addition to identifying these patients, you're also stratifying them by risk. And when I'd say risk in the payer world, it means financial risk, and in a value-based care contract as well risk means financial risk. Now, it's very closely tied to clinical risk. Because, obviously, finances or financial medical costs are driven by how many clinical services are accessed or provided to a particular patient. So when you're doing risk stratification and identification, you're trying to identify and stratify the patients and members who are most likely to benefit from enrollment in your care management efforts.

Aaron Waggoner 39:16
Thank you. So I did have another question that popped through. How do you, how to bridge the gap, when payers don't understand the provider language and vice versa?

Dr. Siv Raman 39:30
You know, I, That's a really tough question to answer. So, truthfully speaking, value-based care if it doesn't align with the incentives for providers as, you know, the fee-for-service system that exists today. So asking a provider to do value-based care is like asking, you know, Jiffy Lube, to sell less called James services or something like that. Right? You know, you're basically saying do less, provide less services, and bill for less services, so that that itself is a foreign concept. And that's the reason why value-based care has not taken off, because from the provider perspective, it doesn't make sense, why should I be trying to reduce my revenue. Now, the flip side of that is that you know, the government, as well as payers, are seeing that the uncontrolled medical cost rise in the US is not sustainable. And so that's the main reason why value-based care has come about. And so when you talk about payers and providers bridging the gap, I think it's not an easy task, for sure, because traditionally, the sets of activities that have been carried out at the two organizations are very different, even though they are working with the same member or patient population. But I think as time goes by, and as more of these contracts are being implemented, we will get to a stage where you will be able to understand, or you know, each side will be able to understand the lingo and the processees of the other side. And therefore, then, you know, they can work in alignment.

Aaron Waggoner 41:39
Great, thank you. So it looks like we've come to the end of our questions. Again, if you have a question, please feel free to type it into that survey, there is an area where you can type in comments and questions. And again, I will get it to Dr. Siv Raman. So I just want to take this opportunity to say thank you so much for attending live today. We always appreciate your attendance and participation in all of our events. And Dr. Sivaraman, thank you so much for presenting to our provider members today. We know that 314e works really hard on this content, and we appreciate it. So any closing remarks?

Dr. Siv Raman 42:18
Yeah, no, I think if there is one takeaway, I think it would be that, you know, even though it's been 10 years, at least 10 years since value-based care started being touted, I think it's been 12 years, actually 12 to 14 years, adoption has been slow; less than 10% of contracts, at appear are where there is any sort of financial risk being borne by the providers. But it is slowly gaining ground. So that's why more and more health systems and providers are having to deal with this. And especially on the technology side, there are a lot of demands being made for Information Technology at the provider to support these efforts. And that's the reason why I think having a set of activities and efforts to manage a value-based care contract at your provider organization, that is something that technology absolutely needs to start thinking about.

Aaron Waggoner 43:38
Great, thank you so much. And I hope that everyone has a really great afternoon. Thank you