Value-Based Care Models: Adopting New Contracts, Addressing Data Challenges

Lynn Carroll, chief operating officer and head of strategy, HSBlox, offers insight into the current shift toward value-based care payment models, challenges regarding data use, and how contracts may be structured in the future.

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I’m Lynn Carroll. I'm the chief operating officer at HSBlox, an Atlanta-based company. We are active in the value-based administration ecosystem within health care here in the United States.

Primarily, we are focused on the administration of what we refer to as cascading contracts, where there are payers, provider organizations, and affiliates, that are either taking full or partial risk on the outcomes for patients.

Can you comment on the current shift toward value-based care?

The shift is interesting. In the current environment, particularly with the continued pandemic, it’s heightened awareness within the health care industry, that we have been very heavily centered on billing transactions, the claim transaction in particular, which is more of a fee-for-service approach.

When there were not a lot of fee-for-service transactions because of the pandemic, it heightened people's awareness that some of the more value-based programs that are about the outcome, the encounter, and precision health-types of initiatives, might be a better way to preserve not only revenue and income into practices and hospital systems, etc, but also to do a more holistic approach to address the different social determinants of health and other equity-related issues that were highlighted by the pandemic.

If you look from a continuum of fee-for-service all the way through to full risk-types of contracts, what you see is a transition away from claim- or billing-centered practices into more patient and precision health encounters that impact the outcome.

What are some challenges to implementing value-based care networks?

Traditionally, when you think about a volume-based or a claim-based mechanism for billing for health care services, these are very individualistic transactions. A more holistic approach is one that looks at the whole patient and therefore involves the whole continuum of care.

There is data sharing that has to occur across the care team, usually multiple stakeholders, that requires connectivity. It also requires an ability to look at a couple different ways of exchanging that data.

Certainly, there are the historical data standards, but there's also a whole host of unstructured data, notes that are in charts, different audio and video pieces of interaction, telehealth side of things, care management, recordings, etc. That contains a significant amount of data that tells you about what's going on with a patient beyond just the billing codes.

Capturing that information and being able to share it is a big part of being able to administer value-based programs. From that standpoint, the challenge, I think, for risk-bearing types of providers is to create that connectivity and that exchange of data, but hopefully in a more real- or near real-time basis. That is what we are focused on within our business, that aspect of things.

What advice would you give to organizations seeking to enact more value-based care initiatives in 2022?

The traditional challenge for providers in taking risk has been getting access to the data and statuses of these contracts, which are being held accountable regarding performance and outcomes. A challenge is, how do I understand the status and my performance with regard to some of the risk-bearing contracts?

Am I going to be in a situation where I might be on the downside risk side? As more folks are taking full or global total cost of care types of risk, the challenge becomes, how am I doing underneath this contract? Do I have the data and the ability to impact things on a timely basis?

Many of these contracts have had 3-, 6-, 9- and 12-month run-out periods before. There's a known incentive or a known risk share that comes out of these contracts. The challenge becomes, if I'm going to do more of these, am I just going to have more of the same, which is a lack of understanding in a more real-time fashion of how I'm performing.

Is this going to be a good contract for me or not? Not knowing that for an extended period of time is not going to be sustainable if I'm going to do a lot of risk sharing.

Where do you see the future going in terms of continued adoption of these contracts and related challenges?

There's 2 pieces to this. One is the value-based side, and the other is a more precision- or patient-centric side. When we think about the patient-centered precision health side of things, we're typically thinking about things that impact ER, impact admissions, readmissions, the things that drive the total cost of care.

Then we also think about chronic disease management. As you look at the ecosystem, there's going to be a continued move to incorporate whole health types of initiatives that are at the community and social services level, bringing in these domains from a social determinants of health side, to help manage these risk contracts.

We're going to see that these contracts will continue to fold those types of organizations in, as it becomes clearer how to reimburse for nontraditional medical services, but more community-based and social service agency incorporation.

Is there anything else you would like to add?

There's probably just a couple things globally to think about. A big part of closing gaps in care has been part of the pay-for-performance incentivization, a part of the ecosystem that sits between both the fee-for-service and true global or risk management contracts.

What we're going to see is that a lot of those are going to transition into more risk-bearing contracts, where there's been more traditional value-based programs that are about pay-for-performance. A lot of these are going to move toward fuller risk-bearing contracts. The patient is going to be folded in for some incentivization as part of a participant in these contracts.