The 4 Cornerstones of Developing a Value-Based Care Model

The new Value-Based Care Model is no different than what the industry was attempting to accomplish in the 1990s with Integrated Delivery Network Managed Care. It’s been 25 years and we still have data integration, referrals and authorization problems across the healthcare delivery continuum. It’s time for payers and providers to work together!

The 4 Cornerstones and their Barriers

  1. Governance: Physicians do not trust hospitals and payers to work in the best interest of physicians and patients
  2. Collaboration: Referrals within and across networks are still not seamless and PCPs rarely receive follow-up responses from specialists or hospitals
  3. Integration: Data integration is difficult between Electronic Health Records (EHR) systems and almost impossible between traditional vendor claims systems and EHRs. Unless you are part of a large closed healthcare network, data integration is next to impossible.
  4. Sharing: Information integration and stakeholder collaboration is not easy due to the many proprietary views of how internal information must be protected

How can we achieve data integration and quality care?

Payer, provider network, and physician information integration and knowledge sharing was never achieved in the ’90s due to a trust breakdown, so it’s critical to build stakeholder trust. The following must be undertaken to facilitate the transformation to Value-Based Care:

Action

Benefit

All stakeholders must respect the patient PCP relationship Quality of care and delivery is achieved
Vendors must build systems that seamlessly integrate referrals and authorizations Integrated procedure and care tracking
Vendors of clinical, claims, and medical management applications must integrate at both the data and process layers Encounters-to-claims supports the care continuum
Integrate all clinical and administrative data to direct population-based analytics Ability to achieve quality care and leverage population health information

My Challenge to the Industry

It’s time to reinvent the industry proprietary model for claims and clinical data. All data must be able to seamlessly integrate and be securely shared across the entire U.S. healthcare delivery system. This is how the manufacturing, distribution, banking, and finance industries have created their efficiencies in information integration. Healthcare needs to do the same. It’s time for everyone to play nice and work together!

The vendors, large health plans, large health systems, and pharma companies have all been complicit in this proprietary, non-sharing of data/information model. Their model has not worked – it must change if ever we are to achieve the promise of Value-Based Care and a real model of Affordable and Accountable Care.

The major stakeholder organizations in the industry, AMA, CAPG, HFMA, HIMSS, MGMA, and WEDI, with the support of CMS and HHS (including all state departments), must come together and create the following:

  • Industry Patient Data Model Standard
  • Industry Standards and Rules for Healthcare Data Integration
  • Healthcare Applications Data and Process Integration Standards

Without these industry leaders enforcing standardized data integration, we will never achieve the U.S. Value-Based Care Model. Do you agree that this needs to happen? Would your organization support such industry mandates? Let us know your thoughts.

If you’d like help transitioning to Value-Based Care, read about HCIM’s Strategic Consulting services.

Dr. Bill Bysinger

Bill Bysinger, Ph.D., MBA
HCIM Sr. Strategic Adviser

Follow HCIM on LinkedIn

About HCIM

Since 2000, HealthCare Information Management, Inc. (HCIM) has delivered expert consulting services and robotic automation tools for small to mid-sized healthcare payer and managed care organizations. Our concierge consulting services include everything from core claims system procurement to go live, including configuration, migration, upgrades, reporting, benefits and fee schedules, user training, and project resourcing. We also offer strategic consulting in the areas of value based payments, population health, medical management, medical loss analysis and recovery, care management, provider contract modeling, data analytics, and business process reengineering/analysis.