The Rapidly Evolving Move to Value-Based Care in a Post-Pandemic World

“We shall have no better conditions in the future if we are satisfied with all those which we have at present. ― Thomas A. Edison 

Value-based care (VBC) and population health management (PHM) will be impacted for years to come as a result of the COVID-19 pandemic. There is little doubt that COVID-19 brought about significant changes in patient care and forced many healthcare providers to adopt VBC strategies as a means of survival. As the healthcare industry continues to struggle with staffing shortages, rising costs of basic supplies, and a growing demand for patient care, the need for a transition to VBC will continue to grow.  

The Rapid Growth of Healthcare Costs 

Our global healthcare system is reaching a breaking point. Expenditures are increasing so rapidly that healthcare spending corresponds to approximately 20% of our gross domestic product (GDP).i It is important to note that, even before COVID-19, healthcare expenditures in the US were expected to rise at 5.4% per year, reaching g $6.2 trillion by 2028.ii Total healthcare spending was close to $1 trillion prior to the pandemic. Sadly, 25% of all US healthcare expenditures are on non-value-adding aspects of the healthcare system. In other words, 25% of healthcare costs are considered wasteful.iii Much of that waste comes in the form of “replacement care,” where patients go to the emergency room (ER) for treatment of chronic conditions and the evaluation of health concerns instead of establishing a relationship with a primary care provider (PCP). Another element that must be considered is long-term care avoidance – patients who know they have a health condition but continually avoid care due to factors often outside of their control, such as cost, transportation, or fear.  

Short-Term Effects with Long-Term Consequences 

The COVID-19 crisis hit hardest among patients with poorly managed chronic conditions such as Type 2 diabetes, obesity, heart disease, and chronic obstructive pulmonary disease (COPD). Many of these conditions are closely tied to social determinates of health (SDoH). Patients with these chronic conditions were left vulnerable during the pandemic and have not received the preventive care they need in over a year. Their vulnerability lies in the fact that many healthcare organizations were not prepared to make the changes needed to support their patients. So, it is not surprising that patients have been avoiding care due to the pandemic, thus reducing revenue for hospitals and provider organizations. As a result, these organizations will have to embark on cost-saving initiatives to make up for losses. They will also have to find new ways to engage patients, provide care, and meet patient needs where they are. 

Pandemic Trends in Healthcare Here to Stay 

The path toward VBC saw a great deal of growth prior to the pandemic: 36% of total US healthcare payments were tied to alternative payment models. HealthEC believes that care organizations will increasingly adopt VBC strategies as the COVID-19 Relief Bill takes effect and Affordable Care Act (ACA) subsidies are increased. To support these strategies, we expect to see the following trends in healthcare gain traction as COVID-19 becomes endemic:  

  • Increased Need for Data: Healthcare organizations participating in VBC models require enhanced real-world data and sophisticated analytics to successfully negotiate contracts and optimally manage their patients. These groups will need increased access to aggregated data from across the healthcare ecosystem to provide the type of proactive care and hotspotting that will reduce expenses yet improve care for their patients. The demand for PHM platforms that include care coordination, SDoH integration, and analytics capabilities will increase as providers and care organizations navigate the new post-pandemic environment. 
  • Heightened Interest in Health Equity: The pandemic has clearly revealed that SDoH plays a large role in getting healthcare. Organizations will move to incorporate assessments for SDoH into their workflows to identify barriers to care that are at the core of health disparities. 
  • Increased Use of Remote Monitoring and Telehealth: COVID-19 has caused providers to rapidly modify their methods of care delivery, with positive results for both patients and health providers. Telemedicine expands access to care and reaches more patients, improves workflows, and increases practice efficiency while reducing practice overhead. Remote monitoring can flag health issues before they become expensive hospital visits, decreasing care avoidance. Patient engagement and compliance increase due to enhanced convenience and access. 
  • Decreased Prescribing of Low-value Testing and Care: Diagnostic tests and care practices that provide little value to patients, such as performing surgery when physical therapy will work equally well or ordering labs for low-risk patients before a low-risk procedure, are typical of fee-for-service (FFS) payment models. This type of care virtually disappeared during the pandemic. A VBC model, where doctors do what is best for their patients, is a better way forward. 

HealthEC’s Solution: Patient-Centered VBC  

To support our clients in responding to these trends, HealthEC’s end-to-end PHM solution includes more than 200 prebuilt, reusable connectors that can connect to and integrate data from across the healthcare ecosystem into our universal data warehouse, and we are adding more connectors every day. Using our FHIR-enabled eConnectors module to access and aggregate virtually all available structured and unstructured electronic healthcare information from hundreds of systems across the healthcare continuum provides our clients with a 360-degree view of their patients as well as their organization. HealthEC’s platform can also integrate with remote monitoring devices, health wearables, and telehealth systems to provide increased data for analytics, risk stratification, and care management. 

HealthEC’s care management module, CareConnect, provides a variety of SDoH and behavioral assessments that evaluate each patient’s health disparities, automatically inform care plans, and schedule interventions. HealthEC’s platform has long included such tools and was recognized by KLAS Research in 2019 for having all KLAS-validated SDoH capabilities compared to other vendors. A 2020 report from Chilmark Research, Addressing Social Determinants of Health: IT Solutions to Engage Community Resources, spotlights HealthEC’s platform as an effective solution for seamlessly connecting healthcare providers with community partners, resulting in significant reductions in unnecessary care expenditures and dramatic improvements in patients’ overall health and well-being. 

And finally, HealthEC’s built-in VBC tools, available within our analytics module, 3D Analytics, provide targeted analyses for optimizing VBC contract negotiations, in-depth financial and utilization reporting, quality measure tracking and gap monitoring, and sophisticated algorithms to risk stratify populations and identify patients for hot-spotting and resource investment. Based on comprehensive, rather than siloed, data, our tools help improve outcomes, minimize low-value and duplicative testing, reduce costs, and optimize the health of an organization’s member population. 

Real-World Examples 

The following examples illustrate how clients utilized HealthEC’s platform to further their own organizational goals as well as respond to trends in the health analytics industry. 

  • Comprising approximately 350 healthcare providers, this New York ACO cares for nearly 6,000 dually eligible Medicare and Medicaid beneficiaries, including a dual-eligible population with IDDs living in group homes, and is the only MSSP-approved ACO of its kind in the United States. The ACO faced a common challenge in healthcare: how to improve care quality and reduce cost. To meet this challenge, HealthEC integrated provider EMRs, an HIE, and pharmacy data into our solution, which enabled the ACO to risk-stratify patients, coordinate care with specialists and other community-based programs, and engage physicians by illustrating opportunities to improve the cost and quality of care. The results were substantial cost savings. 

To decrease the use of ER services, which was excessive, HealthEC created a triage assessment for staff to determine illness severity. ER telemedicine kiosks with access to the HealthEC platform were then placed in the group homes, allowing the ER-trained telehealth providers to view current patient data and enter additional data into the system. HealthEC also created “ready-to-go packets” for transmission to consulting physicians and arranged for post-visit summaries to be transmitted back to the platform. This resulted in a 4.42% reduction in expenditures for 5,975 beneficiaries, an 11% reduction in ER visits, and a 7% reduction in hospital admissions in a single year. 

  • A Midwest IPA uses HealthEC’s platform to integrate physical and behavioral healthcare data from built-in and external assessments and multiple physician and community-based organizations to drive care management and analytics activities. The IPA recently engaged with HealthEC to implement the platform independently for their component practices and to incorporate a proprietary personalized community referral platform into our CareConnect product to facilitate localized community-based referrals to patients. The IPA revised their SDoH workflows to include the option to interact directly with the community referral platform as part of the patient management process to more quickly manage referrals. 

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