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Optimizing Interoperability of Administrative, Clinical Data to Accelerate Value-Based Payment Transition


Several barriers continue to impede the transition to value-based payment, particularly administrative and clinical data connectivity, transparency of quality metrics and quality measures, and prioritization of social determinants of health.

Several barriers continue to impede the transition to value-based payment, particularly administrative and clinical data connectivity, transparency of quality metrics and quality measures, and prioritization of social determinants of health, said April Todd, senior vice president, CORE and Explorations, CAQH.


AJMC®: Hello, I'm Matthew Gavidia. Today on the MJH Life Sciences’ Medical World News, The American Journal of Managed Care® is pleased to welcome April Todd, senior vice president, CORE and Explorations, for CAQH.

Great to have you on, April. Can you just introduce yourself and tell us a little bit about your work?

Todd: Sure, thank you for having me. As you mentioned, I'm April Todd, senior vice president at CAQH, and I lead our CAQH CORE and Explorations initiatives.

AJMC®: First off, can you speak on the progression toward value-based care reimbursement from the traditional fee-for-service model and any impact that COVID-19 has had on either perception or efficacy of each model?

Todd: So, the industry has been moving toward value-based care for a number of years now. And I think one of the things that people have noticed throughout that progression is that there's been a need to have a greater connection between the administrative and clinical sides of the world, to help support the care needs of the patient and also just to help those payment models be administered more administratively simply.

What we've noticed during COVID-19 I think is actually an acceleration of that need, because as you have more even patients coming in and needing to be treated more quickly, and needing to have more of their patient history, having that connection of all of that data available to a provider has even become, I think, more important during this time.

AJMC®: CAQH CORE recently published new operating rules seeking to improve connectivity and accelerate the transition to value-based payments. Can you speak on any notable factors that influenced the design of these new rules and any major takeaways from this announcement?

Todd: Sure. So, let me talk about connectivity first, because I think it's very related to the first question that you asked. One of the things, as I mentioned, that the industry has been struggling with is connecting that administrative and clinical data. And so one of the driving forces behind our connectivity rule—and it is an update to our connectivity role—is to help support that connection between administrative and clinical data.

In particular, what it does is bring in some new technology, the ability to use rest APIs [application programming interfaces], for example, and some new security features that can really help connect the way we have traditionally exchanged administrative data and how folks are looking to, and have been exchanging, clinical data. So, it really helps support that process.

In addition, it also helps to align with new rules that came out from CMS recently related to what we call the interoperability rule that provides patients more access to their data. So, it really is to help connect the whole ecosystem of sharing that information.

Related to value-based payment, those rule sets really start to create the connection between our payment systems and our administrative systems, our payment models and our administrative models. So, we brought an advisory group together of experts a few years ago and asked them what are the major barriers to incorporating value-based payment models into our existing administrative workflow.

The first priority that we heard from them is that providers don't even know which patients they're responsible for. So, that's what we call the patient/provider attribution problem. What we heard is that providers often find out that a patient is there months after they start seeing them or even after the contract is done and so that doesn't help the provider know how they can better care for that patient or know that they are responsible for managing their care.

So, the value-based payment rules that we have recently passed help to solve that foundational problem, in that they create rules that require information to be shared between health plans and providers regarding which provider a patient is attributed to.

AJMC®: What issues continue to impede the transition toward value-based care, and what actions or solutions may better improve interoperability across the health care industry?

Todd: So, there are definitely remaining barriers to value-based payment. As I mentioned, the advisory group that we worked with identified some additional priorities as well that we are going to start to work on this year and into the next year. Some of those barriers include the communication of quality metrics and quality measures.

Oftentimes, that's done through spreadsheets today, it's done through unique online portals, and there isn't really a consistent way to help communicate that information. So, we're going to be doing some pilots and looking at that, as well as our next priority, which is around social determinants of health and helping to find ways to communicate that information as well so that you really have a full picture of a patient and can use all that information to help improve their care. So, those are the key areas that will be next on our list.

AJMC®: Lastly, do you have any other concluding thoughts?

Todd: I think when we talk about both of these rule sets, our goal really is to, as I mentioned before, help connect our payment models and our administrative system. And really, we need to do this because there are concerns with not being able to achieve the savings that we've been promised from value-based payment models because we spend all those savings administering the complex programs that have created those models.

So, what we really are looking to do here is help to incorporate value-based payment into our administrative processes so that we really can achieve those savings and help improve patient care.

AJMC®: To learn more, visit our website at AJMC.com. I’m Matthew Gavidia, thanks for joining us!

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