Transitioning to Value-Based Care and Improving Digital Patient Health Care Journeys

Lynn Carroll, Chief Operating Officer at  HSBlox, Inc, shares his perspective on the increased adoption and future trajectory of value-based care and alternative payment models.  

Tell us about yourself. 

I'm Lynn Carroll, the Chief Operating Officer here at HSBlox, Inc. My background in health care began in the early ’90s in both an operational and technical capacity. I gained experience with a provider-sponsored plan and worked from both a payer and provider perspective.  

In those early days, I was largely working on global capitation contracts. These were percentages of premium deals for a total cost of care, and they weren't called value-based programs at the time. We worked with a lot of group practices and integrated delivery systems throughout the upper Midwest and here we are about 30 years later and what's old is new again.  

Why is there increasing interest in value-based care and alternative payment models in health care right now?  

From our perspective, we see 3 major drivers of interest right now. First, CMS is pushing its populations and beneficiaries towards a target goal of 100% of value-based programs by 2030. That sparks interest on the commercial side as well as with employers. The second driver, and the biggest driver always, is an interest in more cost-containment. This means trying to figure out how we can “bend the curve” of an unsustainable cost structure model.  

Coming out of COVID-19, the third driver is a significant loss of fee-for-service revenue for providers. Folks weren't going to the hospital due to lockdowns or were postponing procedures. These challenges always bring back the question of how can we have a more predictive revenue stream on the provider side? 

Also, during COVID, a lot of health equity issues surfaced and made apparent that a lot of the population was faced with unique challenges around accessing services. There was increased awareness of health equity and social determinant issues regarding care access, level of service, and the tools needed to obtain care that should have been addressed years ago.  

Why are digitized data and analytics at the individual patient journey level necessary for the successful adoption of VBC and alternative payment models?  

The first thing to consider when considering risk-based models under value-based programs is “what am I taking a risk on at either an IDN level or at a primary care panel level?” Answering that question means understanding population health in your cohort of patients. You must ask what's that population look like? Where are my high-touch folks? Where are my more self-sufficient, self-empowered patients? And it always comes down to traditionally using data sets like claims data and administrative data related to fee for service that have been part of the billing cycle.  

As you get into more outcomes-based programs, the data needs to be clinical in nature. It also needs to bring in external data sets that are relevant to a patient's social issues that might be impacting their health and well-being. A lot of this data is unstructured, I believe the stats show that roughly 80% of health care data is in an unstructured format. 

You can glean a lot of knowledge about where folks’ particular needs that might be impacting their health from data besides traditional medical data. Talking about digitized data raises the question is it usable? 

Something we do is apply natural language processing to bring data into a structure where it can be reported on and analyzed alongside more traditional data streams. If you're looking to allocate resources appropriately under a value-based program with a fixed revenue stream and you're accountable for outcomes, you're going to utilize as much data as possible to stratify that population, so you know where to allocate resources. This can lead to more success with a value-based model. 

What are the most significant challenges and potential solutions to this transition?  

An impetus for our platform is that the traditional infrastructures for fee-for-service administration are built to schedule an appointment, issue a bill, and have that claim or invoice paid by an insurance company, a self-insured employer, or a state or federal program. The cycle is fairly fragmented but also straightforward.  

A potential challenge when the process is volume-based is you have an opportunity for duplication of services, unnecessary services, and poor allocation of the health care dollar. As you get into value-based programs, there's a need for the process to be less siloed and to incorporate more care coordination across the continuum for better outcomes and appropriate expenses. 

Data exchange components are important underneath value-based programs, you've got to align primary care and specialty care. A significant amount of the total cost of care programs is generated in the specialty realm, particularly for polychronic individuals. If you're going to hold a primary care physician responsible for the panel of patients that they've been allocated, you need to help align them with specialty care, because primary care can't do it alone. Care coordination also becomes very important when considering the patient experience and outcomes of polychronic patients who see multiple specialists.  

What do you anticipate being the future trajectory of VBC in health care?  

We believe in value-based care and that the trajectory will continue to accelerate, primarily driven by CMS. As we move forward, I think we're going to see commercial payers, as well as employers engaging more around value-based types of programs. Typically, those programs are following a little bit behind the push from CMS, in terms of certainly managing the Medicare and Medicaid populations. And we usually will see commercial populations and employer-based, self-funded populations following closely behind. I think health equity is also in the mix in terms of looking at how health equity issues can be addressed underneath these types of programs, and that will also continue to accelerate the adoption of value-based programs. 

How do payers, providers, patients, and other health care industry stakeholders benefit from moving to a fully digitalized offline-to-online patient journey?  

I think digital health care in general provides an opportunity for significant cost containment and efficiency, particularly when you can care for patients in their homes or in their communities.  Some of the challenges of a fully digital scenario is that some underserved populations are also underserved from a technology standpoint. Thus, the advantages of services like remote monitoring, wearables, and other tools still require some degree of a compliance component.  

While you can gather external readings from devices that end up being near real-time information for intervention and early detection of change in patient status, there's always going to be a need for more high-touch scenarios where a significant amount of the expense is in polychronic individuals. These types of patients are more likely to need a weekly check-in through a care coordination resource to help them navigate not only the system but also the multiple chronic diseases they are managing. 

I think we’re going to continue to see an acceleration of the digital world for things like remote monitoring and capturing data for early detection and also will see a healthy mix of one-to-one, face-to-face interactions with providers, particularly to manage more complex cases. Some challenges also remain in the interoperability area to ensure all care team members have as much up-to-date information as possible. This is important so that patients have a better experience and aren't exposed to duplicative tests or unnecessary procedures. Value-based programs stand to benefit significantly from digital health initiatives.