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Payer Reporting Key to Value-Based Care Success

Savvy payers want physicians to succeed in value-based contracts and provide them with a comprehensive reporting and analytics tool.

To succeed in value-based relationships, physicians need timely access to comprehensive information about attributed patients, ideally augmented by predictive and prescriptive analytics to identify future health risks. Unfortunately, this is not something the typical electronic health record (EHR) can do. That's why it is critical for physician practices to ask questions about payer reporting, ideally before they sign the contract.

The questions physician practices most likely to succeed in value-based relationships ask their payer partners are:

1.     Do you provide participating physicians with an online, on-demand and self-service reporting tool that has drill-down capabilities for further exploration?

Until recently, payers held monthly meetings with participating physicians and used paper charts to review performance. Times have changed. As a result of value-based contracts, payers now expect more of participating physicians. Therefore, physicians need more from payers.

The reporting tools most favored by physicians not only include standard reporting on important activities such as identification of high-cost and high-risk subpopulations for engagement and evaluations of out-of-network utilization for possible redirection to in-network services, but also allow physicians to drill down within all the reports to view and evaluate the underlying numbers.

2.     Can I use your reporting tool with all of my accountable care organization (ACO) and value-based contracts?

The typical physician practice has more than one ACO or value-based contract. Given the already high administrative burden on today's physicians, it is simply unrealistic to expect physicians and their staffs to toggle among as many as 10 different reporting tools throughout the workday.

3.     Does the tool integrate timely data from all sources, including clinical, claims, demographic, psychosocial and more to create a comprehensive, 360-degree view of each patient?

In a value-based environment, it is critical that physicians be able to quickly access a comprehensive picture of each attributed patient. Primary care physicians, for example, too often do not know what happens to their patients outside of their offices. Timely knowledge of which patients are in the hospital, which have been discharged in the past 10 days and how far a discharged patient lives from a pharmacy is the kind of information they need to prevent costly and avoidable readmissions.

4.     How often is the data updated and how frequently do participating physicians access your reporting tool?

Far too frequently, physicians lack access to claims information, and even when they have access, it often lags by months. For physicians to succeed in value-based arrangements, they need timely information to make the best decisions for their population of patients and, when needed, to course-correct. The frequency that physicians and their staff access payer reporting is a bellwether indicator of how often the data is refreshed and how useful the information is.

5.     Does the tool mirror the contract in terms of timeframe, risk adjustment and attribution methodologies, and peer comparisons?

It should go without saying the reporting tool needs to help physicians understand and improve their performance in terms of meeting the measures in the contract; however, too often there are meaningful differences between the contract and the information in the reporting tool that impede physicians' value-based care success.

6.     Does the reporting tool automatically push notifications into my practice's EHR?             

Most providers working in a value-based reimbursement environment have found that an EHR is necessary but not enough, meaning they need more additional capabilities but also seamless data-sharing between the EHR and the reporting tool. To improve physician effectiveness and reduce physician burnout, the reporting tool needs to automatically push notifications into the practice's EHR.

7.     Does the tool tell me aggregate contractual performance-to-date on quality metrics like HEDIS® and Medicare Star ratings, as well as identify which patients still have open quality opportunities?

All value-based contracts measure provider performance on quality metrics like HEDIS® and Medicare Stars. The most sophisticated reporting tools contain timely, accurate scorecards that help providers meet this year's performance goals.

8.     How does the reporting tool help me identify which of my patients are experiencing rising-risk and what kind of care management programs do you have to help me engage those patients before they develop a chronic disease?

Increasingly, predictive and prescriptive analytics allow payers and providers to identify which members are likely to become sick in the next 12 to 24 months and then intervene to prevent chronic illness. For example, some payer reporting tools can identify the pre-diabetics within a patient population, combine this information with preventive care compliance and medication adherence, and then provide prescriptive information to help providers best engage those members in care management resources.

The savviest payers want their participating providers to succeed in value-based contracts. After all, their fates have always been inextricably linked, and that's even truer now. Payers that provide their network physicians with a comprehensive, sophisticated reporting and analytics tool:

·       Set up physicians to succeed in value-based contracts

·       Enhance communication and collaboration between the payer and participating providers through the use of a common tool

·       Improve health outcomes and patient satisfaction.

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About the Author:

Mark A. Caron, CHCIO, FACHE, CEO, Geneia

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