Providers may have some good reasons for moving slowly. Inaccurate and incomplete data are the biggest challenges providers face when entering into value-based payment contracts and that discourages them from taking on downside risk.
Data analysis is an essential part of a value-based payment arrangement, offering providers a deeper understanding of their patients including all the interactions they’ve had with the healthcare system. Additionally, data are used to determine improvement on performance metrics.
For WakeMed Health & Hospitals, based in Raleigh, N.C., data accuracy has been a problem in its work with Blue Cross and Blue Shield of North Carolina, WakeMed executives said. The health system formed a value-based arrangement in 2014 with the Blues plan when the insurer joined its ACO, WakeMed Key Community Care.
Claims sometimes aren’t processed correctly or at all, health system executives said. The discrepancy may even be the fault of the clinician who didn’t record the interaction correctly, but it still causes frustration, said Dr. Brian Klausner, chief medical officer of WakeMed Key Community Care. “If the data isn’t accurate you’re not going to get provider buy-in and you’re not going to get clinical change,” he said.
It’s also caused some hesitancy to take on downside risk initially. “You can’t go into downside risk unless you have good data and clean data,” Klausner said.
In an attempt to address the problem, both WakeMed and the North Carolina Blues now share their data with each other, making it easier to sort through discrepancies, said Dr. Leslie McKinney, lead medical director for value-based provider engagement at the Blues plan. “We’re learning from each other and iterating as we go forward in the relationship,” she added.
Still, imperfect data from insurers shouldn’t be much of a barrier for providers to be successful in value-based payment models, argued Kevin Sears, director of BDC Advisors, a consulting firm for providers and health plans. Physician practices and health systems now have sophisticated electronic health record systems that can perform detailed analyses for them. “While it might be true they aren’t getting great data (from insurers), there is plenty that can be done with basic EHRs,” he said. “It’s really about taking the time to think through how to harness that data and use it to drive performance improvement.”
Incomplete data is often a problem, too. Insurers can’t offer all the information to providers regarding pricing information due to privacy agreements with other provider networks. “That is absolutely frustrating at times,” said Dr. Christopher Crow, president of Texas-based Catalyst Health Network, which includes about 600 primary-care providers.
The network is in value-based payment contracts with UnitedHealthcare, Aetna and other large commercial payers. Crow said sections of data reports from insurers are left blank because they can’t disclose the total cost of care for services at certain organizations.
While UnitedHealthcare can’t reveal specific prices among its customers, it tries to get around that by breaking down cost of services into tiers, Nguyen said.
“We give them a general idea of the potential savings, not explicitly, so we don’t violate contracts,” he said.
Crow said the lack of transparency has stunted what Catalyst Health has been able to achieve. Most of the gains so far have been made by focusing on easy targets such as directing patients to receive scans and colonoscopies in outpatient rather than inpatient settings, but more detailed pricing information data will help them “do more tactical things,” he said. The joint ACO that Catalyst has with UnitedHealthcare has led to $28 million in savings over a two-year period.