Integration

What Exactly is Value-Based Care?

Before we talk about value-based healthcare, let’s first get a basic understanding of the current provider-payer-patient relationship. Traditionally, providers (physicians, hospitals, and the like) are reimbursed via a fee-for-service model. It looks something like this:

  • Provider bills for services (an office visit, ordering a lab test, outpatient surgical procedure, admission to a hospital) they perform

  • Payer pays for these services

  • Patients pay a portion per their health plan

Simply put, you pay for what you use. The overwhelming sentiment of providers and payers is that fee-for-service no longer works and value-based care is going to fix the healthcare system.

UNDERSTANDING THE FLAWS IN FEE-FOR-SERVICE

The fee-for-service model isn’t without flaws. Because profit comes directly from the services performed, healthcare providers may be swayed to perform more and more services, some of which are unnecessary. Have a headache? Let’s get a CT scan. It’s rare a patient will reject a physician’s orders if they deem a service necessary. But this ends up in expensive procedures, most of which could have been avoided.

More services also means a need for sick patients. Providers are not incentivized to keep patients healthy but instead to have sick patients. The more sick patients, the more office visits, labs, and procedures. This doesn’t mean that physicians are practicing in a harmful way, but it may suggest that financial incentives are improperly aligned.

DEFINING VALUE-BASED HEALTHCARE

So, what is value-based care and how does it differ from fee-for-service? The core of value-based care is a changing reimbursement model that pays providers based on the quality of care that is provided. There are several variances of this model:

  • Pay for Performance. An extension of fee-for-service, the provider is still primarily paid based on services plus they receive bonuses or penalties based on the quality of care provided. This model was pioneered by Medicare with the Physician Quality Reporting System (PQRS; replaced by the MACRA/MIPS program). Through PQRS, providers received bonuses (or paid penalties) as a percentage of their Medicare billings based on quality measure results. This doesn’t eliminate fee-for-service, but it does hold providers accountable for the quality of care being delivered. Plus it monitors overuse or reduction of unnecessary services by penalizing providers when those actions are not clinically appropriate (such as unnecessary imaging or prescribing antibiotics)

  • Bundled Payments/Capitation. While there are differences between options, the concept of these models is that a payer will pay a provider/hospital/health system one lump sum for a group or bundle of services. It is then up to the health system to deliver the care for those services. The payment never changes based on the amount or type of services actually provided which incentivizes providers to be efficient in their care delivery as they will not be paid more for extra services. This model is common for episodes of care like a knee replacement surgery.

  • Shared Savings. In this model providers can receive an additional payment if actual costs incurred are lower than projected or benchmarked costs. The savings are split between the payer and the provider. Medicare and Medicaid have paved the way with their shared savings program at accountable care organizations (ACOs).

Quality of care is a major component for value-based care and payments to work. In a bundled payments or shared savings model it is critical to measure quality of care being delivered to ensure that necessary services are not bypassed simply to meet spending goals.

Measuring quality of care is nothing new, payers have long been measuring quality based on claims data. Through claims analysis, payers can easily assess when certain procedures have been performed. But claims data only goes so far in helping you measure quality.

For example, if payers are reimbursing for a large group of patients that have diabetes, a claim can tell the payer if a blood sugar A1c test was performed, but it won’t tell you if the patient’s blood sugar value is under control. To effectively measure quality you need clinical data from an EHR. With clinical data, you have access to data like lab results, blood pressure values (no claim is submitted when taking a blood pressure) and social history such as if a patient is a smoker and if they are were they given cessation counseling.  

This is the differentiator when it comes to value-based care: combining clinical quality data with cost and utilization data.

LEVERAGING INTEROPERABILITY

To successfully combine all the cost and quality data, it’s important to enable multiple systems to talk to each other. Data from claims, practice management systems, EHRs, outside labs, and so on need to be integrated to paint a full picture of value. This remains one of the biggest challenges in healthcare today.  

Great strides are being made with initiatives like the new Fast Healthcare Interoperability Resources (FHIR) standard developed by HL7. FHIR is an open and free standards framework designed to ease the burdens of interoperability. Built using standards like XML and JSON with a focus on ease of implementation, FHIR looks to be a key tool in building value-based care and payment systems for healthcare providers and payers.

At HealthLX, we are proud to support FHIR and HL7 initiatives. HealthLX is a Da Vinci stakeholder working with other industry leaders and health IT technical experts to accelerate the adoption of HL7 Fast Healthcare Interoperability Resources (HL7® FHIR®) as the standard to support and integrate value-based care (VBC) data exchange across communities.

Value-based care is a critical component to fixing our healthcare system. Bringing new payment models, combined with quality measurement and population health, using standards to promote interoperability will create great change in providing better patient care.

News: Casenet and HealthLX Partner to Launch TruCare Linx for Care Management Clinical Interoperability

BEDFORD, MA – June 24, 2015 – Casenet®, LLC, a leading provider of extensible care management solutions, today announced a partnership with HealthLX™ to deliver TruCare Linx™, a new integration engine solution for the healthcare market. TruCare Linx powered by HealthLX provides a proven suite of pre-built components to support the integration of TruCare to existing clinical systems including health information exchanges (HIEs) and electronic medical records systems (EMRs).   

The TruCare Linx integration engine is capable of using a wide range of data message schemas to support HL7, X.12, XML and custom data mappings. The TruCare Linx Standard ADT Message Suite provides a flexible means to accept the HL7 hospital admissions, discharges and transfers (ADT) messages commonly used for care management integration. This approach enables TruCare to be deployed without being dependent on customized backend integration and enables real-time or near real-time notifications of clinical events. TruCare Linx, which is designed specifically for TruCare, can be delivered as an on-premise or hosted-software integration engine to meet the unique needs of Casenet clients.

“We are excited to be partnering with Casenet,” states Will Tesch, CEO of HealthLX and TESCHGlobal. “It is critical for us, all of us, to fully use and leverage health data that is vital to improving patient care.  The power of TruCare combined with the TruCare Linx integration engine delivers unprecedented integrated care management capabilities to the care management market.  This collaboration will help discover and develop better treatments  while improving safety and quality in the delivery of that care.”

Effective care management is facilitated by access to timely clinical information. Understanding and managing changes in member status (such as a pending discharge from a hospital to a skilled nursing facility) allows for more effective care coordination as well as cost management. Additionally, increases to the speed and accuracy in which changes in member status (such as a move to inpatient) can be conveyed to a health plan will enable more effective management of that member resulting in better clinical outcomes and ultimately lower costs. 

TruCare Linx further expands Casenet’s ability to improve care coordination between providers, care managers, coaches, pharmacists, families and members. With a single platform for utilizationcase and disease management, Casenet delivers unmatched flexibility to implement, coordinate and manage clinical, wellness and quality programs. Using TruCare Linx and its current native web services, TruCare can now be more easily integrated with other systems including EMRs, HIEs, predictive modeling and analytic tools, mobile monitoring devices and collaborative care partner systems enabling a holistic view of all members. As a result, TruCare offers an unparalleled intersection of member data, clinical content, business rules and workflow which makes it unique and which raises the bar for care for all members. 

“We are pleased to be partnering with HealthLX,” said Peter Masanotti, Casenet CEO. “By enabling real-time or near-real time access to data from other clinical and administrative systems via TruCare Linx, TruCare will provide care teams with a complete view of its members, enabling truly integrated care management. The result is improved care coordination, member engagement and outcomes as well as reduced time to intervention and cost.”  

 About Casenet, LLC
Casenet provides a comprehensive suite of extensible, enterprise care management software and services solutions for commercial, Medicaid, Medicare, TPA, provider/ACO and carve-out organizations. These solutions enable our customers to improve care coordination and the quality and delivery of care through enhanced case, disease, utilization and home and community-based services management as well as tools for total population management. Casenet supports small to very large enterprise customers that require tremendous scalability, have many lines of business with benefits that are complex and complicated to administer, and require comprehensive configuration for each targeted member population. These solutions enable organizations to meet their unique requirements and adapt quickly to changing market and regulatory dynamics, identify and target populations having distinct risk characteristics and deliver specific care management programs for those members — taking the first step toward better individual health and total population health management. For more information, visit www.casenetllc.com.

Casenet Media Contact:

Kelli L. Bravo, 781-357-2706, kbravo@casenetllc.com

About HealthLX

HealthLX™ (Healthcare Language Exchange) gives new healthcare software solutions instant access to comprehensive patient information and real-time analytics by linking legacy data, applications and processes with modern approaches to application integration. The HealthLX platform is built around a software integration engine that is specifically designed for the interoperability needs of the healthcare industry bridging older legacy systems to newly acquired solutions. HealthLX simplifies the effort and cost of new solution integration by configuring application (HL7, X.12, HIPAA) connectors to meet unique client needs. Designed with enhanced levels of transaction monitoring and security the integration platform ensures message integrity and delivery. HealthLX implementation services are provided through its parent company, TESCHGlobal - an experienced healthcare-focused professional services firm specializing in enterprise integration and business intelligence. For more information, visit www.healthlx.com.

HealthLX Media Contact:

Brian.Bezanson@healthlx.com

Learn more about TruCare®

Request a demonstration and find out how TruCare can improve your member health

Patients and care providers are missing opportunities to improve people’s health and welfare when information about care or health status is not  easily available. It is critical for us, all of us, to  fully use  and leverage the health data that is vital to improving patient care. Doing so will help us discover and develop better treatments  while improving safety and quality in the delivery of that care.

Our Role in Healthcare Innovation

The way healthcare data is organized today is highly complex and not change ready. There is little to no governance which leads to multiple truths, broken systems, and maintenance and upgrades that can be extremely costly.

Specialization and increasing industry change are forces that continue to contribute to the problems of connecting applications and their data. Whether you are a local or state government, public health organization, healthcare provider or payor, the exchange of clinical information will be critical to meet both regulatory and business viability in the future. Unstable data systems create an environment where both personal security and compliance can easily be breached and we need to avoid this at all costs.

Your future, along with the future of today’s healthcare recipients, depends on choosing the right integration governance solution that efficiently creates and manages intelligent integrations, adequately manages those integrations, and effectively manages and monitors ongoing dataflow.

Doing our part to make a difference in our data-complex world, we developed a revolutionary healthcare product, HealthLX (Healthcare Language Exchange), that was designed with three critically important integration governance capabilities:

  1. Integration connectivity that supports a broad level of service orchestration and data integrity between source and target applications.

  2. Effective HIPAA compliant security between systems supporting enterprise-wide auditability and application service level management.

  3. Monitoring and management of dataflow at the transaction level for enhanced visibility for system-wide performance measurement.

Creating Integrations: HealthLX leverages modern integration best practices and Open-Source technologies to create intelligent connectors that interface source data and external APIs. As a result, creating new integrations is easy and repeatable.

Managing Integrations: Existing connections need to adapt over time to changes in data sources, API’s and functional applications. Because connections are mapped inside the HealthLX integration hub, updating and changing integrations is easier to accomplish.

Managing Dataflow: HealthLX’s management dashboard provides an audit trail of every transaction that passes through it and flags failed transactions providing high levels of security and compliance.

CONNECTING THE WORLD, ONE INNOVATION AT A TIME.

Your Clients are Looking to You for Integration Leadership

It might seem daunting, since transaction and data integration may not be in your wheelhouse, but potential prospects and customers are looking to you for integration leadership.

If you are selling software solutions into the healthcare market, you are selling into a crowded and growing space. Decision cycles get extended, pricing pressures are greater, and the need to interoperate with external systems and data sources is more complex than ever. In addition, integration's rapidly growing importance is moving the market to a much more prominent role in selections and negotiations.

Being in a position to see a number of in-flight software deals, I can assure you that now is the time to turn integration into a competitive advantage for you and your solution.

Here are some recommendations for making this happen:

  • Start by making integration a part of your early-stage qualification process

  • Be prepared for one or more of your competitors to make integration an issue

  • Prepare yourself to be the competitor that uses integration to create competitive advantage

These are fearful propositions because integration may not be a strength for you or your organization, it may slow down the sales process, and your prospective client may not be giving signs that it's a big deal.

Tips on getting started down the path of integration leadership:

  • Understand that nobody has all the answers or solutions - so nobody expects you to know or have all the answers

  • Discover who the thought leaders and forces are that are bringing integration to the forefront (see Will Tesch's latest blog entries for ideas)

  • Determine who in your organization has the most integration knowledge and spend time with them to gain additional insight

Our experience shows that knowledge and understanding are key elements to becoming an integration leader. Remember, your clients are looking to you for solutions and integration leadership plays a big role in gaining that competitive advantage.