What You Should Know:

– Edward-Elmhurst Health (NS-EEH) has announced a significant, long-term partnership with Lumeris, a pioneer in value-based care (VBC). This partnership is a major development in the healthcare industry, representing the largest VBC provider deal since 2018.

– With rising expenses outpacing reimbursement rates, health systems and physician organizations are increasingly turning to value-based care to avoid layoffs and service cuts. NS-EEH, the third largest healthcare delivery system in Illinois, comprises nine hospitals, 25,000 team members, and 300 local offices, serving over 4.2 million residents.

Collaboration aims to drive coordinated care and improve quality while reducing costs

NS-EEH will strengthen its clinically integrated network (CIN) by incorporating Lumeris’ population health data platform into its value-based care strategy. The two organizations also plan to deliver joint services, supporting the CIN’s healthcare providers in care management, pharmacy management, patient engagement and other key areas. NS-EEH’s CIN includes more than 3,000 system-employed physicians, affiliated physicians and advanced practice providers, and nine hospitals across Chicagoland.

In collaboration with Lumeris, the organizations will manage joint risk arrangements, leveraging AI as a central component of their technology and approach. Lumeris stands out as the only value-based care enablement company with experience working across various patient populations, including those covered by Medicare Advantage, CMMI programs, commercial insurance, and Medicaid. This partnership aims to enhance collaboration among patients, physicians, and care teams, ultimately leading to improved clinical outcomes, a better experience for both patients and providers, and more efficient management of healthcare costs.

Formation of New ACO Models

Furthermore, NS-EEH and Lumeris will work together to address healthcare disparities in underserved communities by establishing new models of care under the accountable care organization (ACO) framework. Initially, NS-EEH and Lumeris will focus on the opportunity to participate in the Centers for Medicare & Medicaid Services’ (CMS) ACO Realizing Equity, Access, and Community Health (ACO REACH) model. This advanced value-based care model seeks to streamline care coordination and improve health outcomes for traditional Medicare patients. In the future, the partner organizations will expand their focus to include other types of accountable care and population health models to serve our diverse communities.

Given Artificial Intelligence’s potential to improve patient care and reduce costs, it’s no surprise that AI applications are gaining momentum in health care. As your organization explores the benefits of AI in your journey towards Value-Based Care, however, you need to carefully assess the implications, for better and worse.

Evaluating AI implications can be tricky. Healthcare AI varies widely, with clinical technology paving the way for advancements in diagnostics and treatment. But pressure on ACOs to achieve savings is spurring consideration of machine assistants for customary clinician services. That’s the message of one recent study suggesting that AI chatbots may outperform physicians in communicating with patients, offering higher-quality responses and displaying greater empathy. The study evaluated how chatbots versus physicians responded to 195 patient questions from Reddit’s r/AskDocs. Surprisingly, healthcare professionals who reviewed the responses favored chatbot answers over those from physicians in terms of quality (78.5 to 22.1 percent) and empathy (45.1 to 4.6 percent). Not a great report card for physicians!

But before planning to use chatbots in patient education, navigation, and coaching – especially given staffing shortages in health care – ACOs should closely examine the underlying assumptions. Consider these very human factors: How do patients feel about discussing treatment plans with chatbots? Was the study validated and reviewed by peers?  What were the study’s limitations and biases? Did physicians couch their responses with caution due to liability or clinical concerns? Either could have negatively affected the tone of physician communications.

The rapid adoption of AI technology risks incorporating human biases into algorithms, perpetuating gender and race biases through AI healthcare recommendations. Before jumping on the AI bandwagon, we need a better understanding of the effects on physicians and patients, as well as a thorough evaluation of potential unintended consequences.

There may be an advantage in time and money to using chatbots to assist in patient education and to support—not replace–human roles in medicine. We still need to preserve essential conversations between patients and physicians to maintain trust. Ceding that direct communication to technology could erode the patient-physician relationship. It would also undermine efforts to recruit talent into the healthcare profession, where shortages of skilled clinicians is already a significant issue, especially in rural and poorer communities.

Under pressure to adapt to Risk, many ACO stakeholders may be eager to deploy AI solutions. To resist being swept up by the momentum, carefully consider your options, support your participating clinicians in their clinical AI applications, and explore how you might collaborate.

Here are three guidelines for leveraging AI to strengthen your organization while recognizing potential weaknesses of machine-based systems:

1. Use AI to analyze complex data for risk identification, patterns, and variations in healthcare services and costs. AI’s ability to efficiently analyze diverse datasets aligns well with Value-Based Care. Personalized treatment plans based on multiple patient data points can be developed using AI analysis. For instance, AI algorithms can drive episodes of care, enabling ACOs to compare procedure costs, reduce variations, target patients for clinical review, and identify opportunities for improvement. However, be sure to exercise caution and scrutinize algorithms for potential biases that may impact population groups and health equity.
   
2. Evaluate the use of AI in creating patient materials for review by clinicians. ACOs have a responsibility to provide patients with factual information, support medical decision-making, promote cost transparency, and engage patients and their families in the process. Chatbot-generated communications, subject to clinical review, can be an efficient way to develop the necessary tools.
3. Defer replacement of direct communications with patients with AI and test the programs first. Pilot AI-driven communication and education tools, such as patient check-ins and self-management programs, with evaluation of changes in outcomes and patient acceptance. The urgency to utilize data wisely will drive ACOs toward AI solutions. Remember that technology is never neutral. Plan carefully for human and non-human resources to ensure that any AI applications benefit your organization and avoid potential, significant harm.
   

About Theresa Hush

As CEO and Co-founder of Roji Health Intelligence, Theresa Hush is a healthcare strategist and change expert with experience across the health care spectrum, including public, non-profit and private sectors. Her accomplishments include leading the transformation of Blue Cross Blue Shield regulations in Illinois, improving access to care as Director of the Illinois Medicaid program, and serving in executive leadership for both private payers and physician organizations. An expert at creating consensus for desired change through education and collaboration, Terry helps organizations take actions that will direct their future through meaningful technology and programs.

Given Artificial Intelligence’s potential to improve patient care and reduce costs, it’s no surprise that AI applications are gaining momentum in health care. As your organization explores the benefits of AI in your journey towards Value-Based Care, however, you need to carefully assess the implications, for better and worse.

Evaluating AI implications can be tricky. Healthcare AI varies widely, with clinical technology paving the way for advancements in diagnostics and treatment. But pressure on ACOs to achieve savings is spurring consideration of machine assistants for customary clinician services. That’s the message of one recent study suggesting that AI chatbots may outperform physicians in communicating with patients, offering higher-quality responses and displaying greater empathy. The study evaluated how chatbots versus physicians responded to 195 patient questions from Reddit’s r/AskDocs. Surprisingly, healthcare professionals who reviewed the responses favored chatbot answers over those from physicians in terms of quality (78.5 to 22.1 percent) and empathy (45.1 to 4.6 percent). Not a great report card for physicians!

But before planning to use chatbots in patient education, navigation, and coaching – especially given staffing shortages in health care – ACOs should closely examine the underlying assumptions. Consider these very human factors: How do patients feel about discussing treatment plans with chatbots? Was the study validated and reviewed by peers?  What were the study’s limitations and biases? Did physicians couch their responses with caution due to liability or clinical concerns? Either could have negatively affected the tone of physician communications.

The rapid adoption of AI technology risks incorporating human biases into algorithms, perpetuating gender and race biases through AI healthcare recommendations. Before jumping on the AI bandwagon, we need a better understanding of the effects on physicians and patients, as well as a thorough evaluation of potential unintended consequences.

There may be an advantage in time and money to using chatbots to assist in patient education and to support—not replace–human roles in medicine. We still need to preserve essential conversations between patients and physicians to maintain trust. Ceding that direct communication to technology could erode the patient-physician relationship. It would also undermine efforts to recruit talent into the healthcare profession, where shortages of skilled clinicians is already a significant issue, especially in rural and poorer communities.

Under pressure to adapt to Risk, many ACO stakeholders may be eager to deploy AI solutions. To resist being swept up by the momentum, carefully consider your options, support your participating clinicians in their clinical AI applications, and explore how you might collaborate.

Here are three guidelines for leveraging AI to strengthen your organization while recognizing potential weaknesses of machine-based systems:

1. Use AI to analyze complex data for risk identification, patterns, and variations in healthcare services and costs. AI’s ability to efficiently analyze diverse datasets aligns well with Value-Based Care. Personalized treatment plans based on multiple patient data points can be developed using AI analysis. For instance, AI algorithms can drive episodes of care, enabling ACOs to compare procedure costs, reduce variations, target patients for clinical review, and identify opportunities for improvement. However, be sure to exercise caution and scrutinize algorithms for potential biases that may impact population groups and health equity.
   
2. Evaluate the use of AI in creating patient materials for review by clinicians. ACOs have a responsibility to provide patients with factual information, support medical decision-making, promote cost transparency, and engage patients and their families in the process. Chatbot-generated communications, subject to clinical review, can be an efficient way to develop the necessary tools.
3. Defer replacement of direct communications with patients with AI and test the programs first. Pilot AI-driven communication and education tools, such as patient check-ins and self-management programs, with evaluation of changes in outcomes and patient acceptance. The urgency to utilize data wisely will drive ACOs toward AI solutions. Remember that technology is never neutral. Plan carefully for human and non-human resources to ensure that any AI applications benefit your organization and avoid potential, significant harm.
   

About Theresa Hush

As CEO and Co-founder of Roji Health Intelligence, Theresa Hush is a healthcare strategist and change expert with experience across the healthcare spectrum, including public, non-profit and private sectors. Her accomplishments include leading the transformation of Blue Cross Blue Shield regulations in Illinois, improving access to care as Director of the Illinois Medicaid program, and serving in executive leadership for both private payers and physician organizations. An expert at creating consensus for desired change through education and collaboration, Terry helps organizations take actions that will direct their future through meaningful technology and programs.

The VBC delivery model encompasses various approaches with the most common being Accountable Care Organisations (ACOs) and Integrated Delivery Networks (IDNs) in the US and  Integrated Care Systems (ICS) in the UK.  Both countries’ approaches are networks of healthcare providers (hospitals and physicians) who work together to deliver high-quality coordinated care to beneficiaries while controlling costs.  The benefits of VBC models include better patient health outcomes at a lower cost, streamline delivery via coordinated care teams, focused preventative care and treatment plans for patients, less physician burnout, lower costs for payers, and a healthier patient population due to better adherence to treatment.  

While there are many benefits to VBC, there are also some significant obstacles that must be overcome for this type of healthcare delivery model to be a success.  This includes dealing with disparate IT and health records systems, outdated workflows, and lack of internal resources which is a consequence of patients seeing multiple physicians, specialists, etc. who are using different data handling platforms throughout the course of treatment.

When it comes to VBC IT solutions, there are six tools that are essential for tracking, monitoring, and measuring patient outcomes.  These include IT tools to identify patient cohorts, segment patients by risk, aid clinical decision-making, manage care coordination, carry out patient activation, and finally, measure performance and report outcomes.  

Over the years, Signify Research has had the opportunity to speak to 100s of VBC decision-makers and buyers from ACOs and IDNs in the US and similar organizations internationally about their healthcare IT needs.  Our conversations with these organizations have provided greater insights into the current drawbacks of utilizing these technologies as well as what needs to change to improve these IT tools for the better. 

Tools to Identify Patient Cohorts

Our research has highlighted that electronic health record (EHR) systems are the main sources of patient information that are used to identify specific patient cohorts to target as part of VBC, coupled with manual data handling processes.  EHR systems can vary across providers’ settings, with some being more basic with limited clinical decision support (CDS) on offer including minimal highlighting of care gaps and no priority ranking of patients or insights on the financial impacts of closing these care gaps.  EHR systems that are more advanced tend to provide modules that have robust CDS that highlight actions to prioritize patients and provide some input on the cost impact of closing care gaps.  

However, gathering this information to identify patient cohorts to target for VBC is not always a straightforward process.  A majority of ACOs and IDNs that leverage EHR systems to identify patients use a mixture of DIY business intelligence tools such as Tableau, PowerBI, and Excel, for example, combined with some form of a dedicated commercial health insights solution drawing on EHR data.  This process is not straightforward and involves interrogating multiple data sources in various locations to develop a fuller patient view that includes manually pulling data from EHRs/Data Warehouses, claims portals (US-only), self-developed DIY tools, and social determinants of health (SDoH) tools.  Having to pull in data from multiple sources manually does not always display in a way that can help these organizations clinically, especially when some of the data is insignificant or inaccurate.    

When identifying patients to target for VBC, key things that care management teams look at include frequency of hospital admissions/readmissions, frequency of ED visits, type and number of chronic conditions, social needs data, medication spending, and screening tests.  As VBC organizations continue to grow and mature, the demand for more data points beyond EHRs is becoming increasingly important to help accurately identify patients to close care gaps.  With this comes growing interest in the need for sophisticated IT tools that automate processes and improve current workflows. 

Tools to Risk Stratify Patient Cohorts

The VBC providers we have spoken to have highlighted a reliance on several off-the-shelf algorithms that are used to segment patient cohorts identified from EHRs into high-risk/low-risk categories as a way of prioritizing who needs immediate interventions and care plans.  The algorithms in use include, for example, Milliman RX, Hierarchical Condition Category (HCC), Charlson Comorbidity Index, QAdmission Risk Algorithm (UK), Electronic Frailty Index (UK), and Kaiser Triangle.

The reliance on these algorithms once again requires care management teams to utilize manual data handling processes that include a mix of self-developed business intelligence tools combined with some health insights software.  As risk stratification is an important part of VBC, most organizations are currently not using sophisticated tools for various reasons related to issues of cost and lack of internal resources.  But the interest and need are there to look at IT tools that can improve workflows and help to focus on high-risk, high-cost patients in a more efficient and less laborious manner.

Clinical Decision Support Tools

Across VBC organizations we have engaged with, there is a wide variety of CDS software tools in use depending on where the ACO, IDN or other organization is based on their IT set-up journey.  Some have minimal or no CDS tools for closing gaps in care and rely entirely on manual processes to find and prioritize patients for care plans.  Other organizations have CDS support in the form of limited actionability that provides some software assistance with identifying cohorts but still requires manual work to input/extract relevant patient data.  The most advanced VBC organizations have developed integrated tools/dashboards that are combined with cohort identification and risk stratification IT tools and CDS modules providing care gap closure recommendations. 

While advanced CDS setup is what most organizations aspire to, the system is still not perfected as many CDS options are not integrated with care coordination team workflows requiring timely manual processes and additional staff resources.  There is a growing demand for the use of mature, integrated tools that mirror the VBC journey and bundle cohort identification, risk stratification, and CDS in health insights into one seamless end-to-end workflow.  

Population Health Management Tools

Another health IT needs includes improvements to current population health management (PHM) tools on the market.  Many organizations currently use broader dedicated PHM tools that enable care management teams to view cohorts based on risk and then drill down into specific patients to receive input and advice on what actions are needed to close gaps in care.  This specialized software allows for data visualization of common actions across cohorts that would lead to the greatest impact from a financial and clinical perspective.  

While dedicated PHM software is mostly used in medium to large-scale VBC organizations, many of the buyers we have spoken to have highlighted the dissatisfaction that cohort ID is mostly from siloed data sources that are not always accurate or up to date which increases the potential for patients to be incorrectly prioritized.  Also, many of the tools are not as user-friendly and require dedicated support from the IT/informatics team to manipulate data.  The demand is for solutions that not only provide a holistic patient view but also can be easily manipulated by care management teams without having to rely on technical or informatics expertise.  

Patient Activation and Outreach Tools

Our conversations with VBC decision-makers and buyers have also illustrated that despite the demand and use of IT tools for PHM, the telephone remains the primary method of contacting patients and enrolling them into VBC.  Enrollment success varies greatly across organizations, with some leveraging additional outreach tools such as texting tools and various patient apps and portals to contact patients.  

Patient communication is initiated and managed via workflows that once again originate from the EHR which houses patient contact information.  Organizations that have smaller, less diverse populations and those who have either invested in specific PHM IT tools to manage the process or who have developed their own in-house IT tend to experience higher patient enrollment in VBC.

However, while not high on the IT improvement wish list, many VBC buyers have expressed a desire to access outreach tools that better integrate with other care coordination workflows to streamline and expedite patient outreach activities and generate engagement.  

Reporting and Performance Tracking Tools 

To judge the eligibility of ACOs and IDNs for reimbursement payments and shared cost-savings, these organizations are required to participate in annual audits that measure performance and track outcomes.  Analyzing data for these audits is extremely valuable, but it tends to be a labor-intensive process and many healthcare organizations lack adequate resources and skill sets to create these reports.

Currently, most organizations use some form of DIY BI tools created by internal staff to track various program success metrics and KPIs around strategy, operational, and process improvements.  Most medium-to-large scale organizations rely on internal data analytics/informatics teams to develop IT tools via Tableau, Excel, Qlik that provide details on specific performance measures. 

This method of reporting again requires an abundance of manual tracking/reporting activities with automated tools used less commonly.  And this reliance on specific data analyst teams creates a backlog of reporting which makes it impossible to monitor performance in real time so strategies can be implemented to correct or improve outcomes before year-end.   

What PHM solutions are truly needed?

In summary, the six types of health insights IT tools that are essential for VBC organizations are not without significant drawbacks.  What is clearly not working is the lack of a holistic 360-degree patient view, and data limitations in terms of latency and access with multiple data feeds leading to missing and outdated patient information.  With the variety of vendor PHM IT tools in use that are falling short and still need to rely on manual processes, there are growing challenges in creating clear, coordinated workflows that share information back and forth between care management teams and frontline providers.  

Our conversations with VBC healthcare leaders have illuminated three key purchase drivers for any PHM IT tool which includes examining how these tools improve patient care, improve clinical staff workflow/efficiency, and reduce data fragmentation/data siloes.  What is needed for VBC are IT tools that ensure actions recommended by dedicated care management teams are visible and front-facing for providers to act upon as they interact with patients.   Also, having real-time data feeds and tools to inform care management would be extremely beneficial to VBC organizations in terms of monitoring and improving healthcare outcomes.

About Rohinee Lal 

Rohinee Lal is the Principal Analyst at Signify Research, a research advisory company providing healthtech marketing intelligence powered by data. Rohinee joined Signify Research’s Custom Research & Consultancy team in early 2022. She brings over 24 years of experience collecting, analyzing, & presenting market intelligence across various industries including pharmaceuticals, medical devices & digital health.

What You Should Know:

– Aledade is continuing its strong momentum today, announcing that Cigna Healthcare Medicare Advantage customers can now receive value-based care from Aledade’s network of independent primary care practices.

– Participating practices can access Aledade’s cutting-edge data analytics, user-friendly guided workflows, and health care policy expertise, as well as integrated care services supported by AledadeCare Solutions.

– This news comes shortly after Aledade announced a 10-year collaboration with Humana, and a partnership with CareFirst Blue Cross and Blue Shield to advance value-based care to more independent physicians. 

What You Should Know:

– Lumeris is launching Tribus, a value-based care accelerator for practices to convert from fee-for-service to value-based care using a community based-model.

– Under the direction of Dr. Chuck Willey, CEO of Tribus, who is a practicing internal medical physician in St. Louis, doctors will participate in physician-to-physician training and mentorship for anyone looking for a better way to deliver at-risk care for senior populations.

Why It Matters

The Medicare population is projected to be nearly a quarter of the U.S. population in the next ten years. With health systems influencing the vast majority of expenditures for healthcare delivery in the United States, Tribus supports coordinating the experience of care across all venues of delivery. This is accomplished in a shared risk partnership structure where Lumeris is aligned around driving performance outcomes with the participating physician partners.

“It’s an accelerated, community-based approach for practices to convert from fee-for-service to value-based care by learning directly from doctors who have operated in this model for decades,” said John Fryer, President of Tribus and SVP of National Markets at Lumeris. “For practices that want to convert to total cost of care arrangements and are ready to make the leap, this is hand-to-hand work that drives quality patient outcomes, satisfied consumers and solid financials for physicians, payer partners and ultimately patients.”

What You Should Know:

– Providers believe 96% of payment is now value-based in some capacity, and 58% believe their EHR vendor won’t be able to support the data strategies required to thrive under value-based care, according to a new study conducted by Morning Consult and Innovaccer.

– The 37-page national research study uncovers key IT infrastructure issues healthcare leaders said are impeding or essential for progress towards accelerating their transformation to value-based care.

The State and Science of Value Based Care

Only 4% of providers today report using pure FFS with no links to quality and value, and that plummets to 1% by 2025. Providers believe the payment model that’s historically dominated in healthcare has flamed out, and that 96% of healthcare payment today has connections to care quality, cost reductions and, in some cases, patient experience. That leaps to 99% by 2025.

Moreover, while providers report they have moved 96% of their revenue into some form of performance risk, 80% of those programs operate on a FFS architecture, where claims submission (as opposed to population-based payment) remains the driving force for value-based analysis and payment. The FFS architecture is even present in Shared Savings models, according to respondents, where healthcare costs are compared with a goal, and providers and payers share in the savings or losses.

– 58% said they didn’t believe their EHR vendor could support their enterprise data strategy.

– 42% said their data is highly fragmented and siloed, a blind spot for insights, workflows, actions, and reporting essential for value-based care delivery.

– 48% said they’re not confident their organization has the infrastructure to capture and use the full range of patient data.

– 41% said their organization needs population health analytics to advance their enterprise data/information strategy, making it the #1 capability sought among ten priorities offered.

– 68% said their organization doesn’t have the AI capabilities to drive digital transformation essential for value-based care.

– 69% of healthcare leaders said they aren’t using technology to identify at-risk patients.

– Despite a 94% increase in the number of executives who expect consumer-generated data to have a high impact on SDoH by 2025, 72% of respondents aren’t integrating medical and social determinants data.

In addition to presenting key findings on providers’ outlook on value-based care, the State and Science of Value-Based Care report covers value-based care challenges and opportunities reported by respondents; addresses the people, process, and technology gaps respondents said must be bridged; and provides expert commentary and guidance to help providers to put their data to work to accelerate their transition to value.

“The research shows a strong relationship between an organization’s investment in modern digital infrastructure and their ability to succeed with value-based payment models,” Stevens said. “Digital investments will be the deciding factor for more mature risk-bearing organizations. The key to value-based care is the ability to integrate data from EHRs and other IT silos—clinical, claims, labs, pharmacy, telehealth, remote monitoring, social determinants, consumer-generated, you name it—into a unified patient record that lets providers drive the analytics-driven workflows, care management, risk stratification, and patient engagement strategies to drive better outcomes at a lower cost.”

For more information, download the State and Science of Value-Based Care

For the better part of a decade, the shift toward value-based care in the U.S. has been driven by the establishment of the Center for Medicare and Medicaid Innovation (CMMI). Working to develop, test and evaluate new payment and delivery models in Medicare, Medicaid and the Children’s Health Insurance Program, CMMI has taken aim at improving the provider experience, generating better patient outcomes and reducing the overall cost of care.

Recently, CMMI stated that by 2030 every Medicare beneficiary should be in a value-based relationship – either an ACO or ACO-like model or Medicare Advantage – with a significant emphasis on health equity. 

Historically, CMS models have focused on enabling providers to increase accountability for patients’ health through ACO condition-specific models and payer-supported models like Medicare Advantage. However, with approximately 13 active models, CMS has been consolidating and simplifying their models, resulting in fewer disease-specific models and a focus on making provider and patient enrollment easier. 

To succeed across the spectrum of risk, especially as provider enterprises assume more risk and accountability for holistic patient care, they must invest in the right infrastructure that delivers differentiated patient and provider experiences, while producing better clinical, financial and operational outcomes. For this to happen, provider enterprises must focus on the following key strategies:

1. A primary care-led delivery model with enhanced virtual care and clinician access, supported by high-risk clinics. In this model, primary care physicians are supported by a robust infrastructure and given tools to focus on their overall panel, while the patients requiring the most attention are provided with focused support by high-risk clinics. With aligned incentives, primary care physicians can keep expanding their managed care panels, thereby reducing access issues, while thriving in value-based contracts. 

2. Robust medical management infrastructure to meet patient needs for specialty, acute, facility, home and post-acute care needs. This approach brings specialists and facilities in with the right capitation models and incentivizes them to improve care outcomes while optimizing utilization. 

3. Differentiated patient experience to improve satisfaction, clinical outcomes and loyalty. Ensuring that patients can navigate the complex healthcare system with the right blend of technology and staff increases the likelihood of the best outcomes for patients. To do so, care teams and primary care physicians should focus on ensuring patients have the most possible choices, potentially through on-demand access. 

4. Leveraging data and analytics. While there are an increasing number of data sources, the lack of interoperability and data silos still make it difficult to build the full picture of a patient’s health and overall well-being (including SDoH), which sub-optimizes outcomes. Investing in solutions that enable the unification of all data into a single platform, drawing correlations and proactively identifying at-risk and emerging-risk patients at each step of the journey is invaluable in intervening at the right time. 

5. Designing programs and infrastructure with health equity in mind. The need to drive improved health in our communities is critical and is being propelled by CMS’ 2030 objective. Moving forward, organizations will have to build infrastructure that can collect health equity data, report on it and service all Medicare beneficiaries. Without timely investments now, practice operations, reimbursement and ultimately patient care will fall behind.

6. Building a cost-efficient and scalable infrastructure. To succeed in the ever-evolving and dynamic reimbursement environment, provider enterprises need to figure out the best way to structure their care delivery operations and focus on their core strengths, while mission-supportive chores are delegated to effectively create a scalable, asset-light infrastructure that adapts to their changing needs. 

The underlying theme across all these efforts is an acceleration toward value-based payment models that focus on driving more accountability for providers and improving health outcomes for patients. Provider organizations must be cognizant of the 2030 goals as they build patient-centric and physician-led models that help them succeed across the spectrum of risk. 

About Siddharth Thakkar 

Siddharth Thakkar is Vice President, Product and Marketing at IKS Health, a scalable, proven, cloud-based physician enablement platform that enables provider enterprises to deliver better, safer and more efficient care through a strategic blend of technology and expertise.

What You Should Know:

– Three leading organizations that provide healthcare services to senior living communities – Elite Patient Care, Provider Health Services, and AllyAlign Health – have joined forces to form Curana Health. Curana Health’s mission is to improve the health, happiness, and dignity of senior living residents. The Curana Health ACO is a value-based care program for original Medicare beneficiaries.

– The combined Curana Health organization spans 26 states and over 1000+ senior living community partners. The organization includes a medical group (Curana Health Medical Group), an operator of Medicare Advantage health plans (AllyAlign Health), and an Accountable Care Organization (Curana Health ACO).

 Curana Health Medical Group

The combined Curana Health organization spans 26 states and over 1000+ senior living community partners. The organization includes a medical group (Curana Health Medical Group), an operator of Medicare Advantage health plans (AllyAlign Health), and an Accountable Care Organization (Curana Health ACO). The Curana Health Medical Group is comprised of over 400 physicians, nurse practitioners, and physician assistants that provide outstanding primary care, post-acute care and other clinical services in senior living communities, including skilled nursing facilities, life plan communities, assisted living facilities, and memory care facilities.

The Medicare Advantage health plan division of Curana Health will continue to operate under the AllyAlign Health name. AllyAlign supported health plans have demonstrated remarkable results over the last 8 years including a 37% reduction in total hospital admissions among Medicare Advantage I-SNP (Institutional Special Needs Plan) members, a 96% rate of satisfaction with clinical services among members, and a 5-STAR rating by CMS (the highest possible) in the first health plan AAH has managed that has received a CMS STAR rating.

“Curana Health Medical Group’s clinical model brings greater fulfillment to clinicians, better outcomes for patients, and seamless communication with families and facility staff. We are uniquely well-positioned to drive the success of value-based-care programs in senior living communities and look forward to continued rapid growth,” said Dr. Antonio Gamboa, President of the Curana Health Medical Group

What You Should Know:

– Vytalize Health raises over $50 million to advance its value-based care platform for seniors helping primary care doctors strengthen relationships with their patients through data-driven, holistic, and personalized care.

– Led by Enhanced Healthcare Partners, the financing round signals an enormous opportunity for Vytalize Health to accelerate the adoption of value-based care programs by providers.

Vytalize Health, a leading value-based care platform for seniors, announced it has closed over $50 million in Series B financing led by Enhanced Healthcare Partners. The round was also joined by Series A lead Kittyhawk Ventures, as well as Kawn Ventures, North Coast Ventures, and other existing investors.

Specializing in Medicare Value-Based Care Programs

Vytalize Health started as a Medicare-focused primary care practice in New York in 2014. The company developed a vertically integrated solution combining a risk-bearing entity, virtual and in-home clinic, and broad technology platform, which they then began offering to other primary care practices in 2017.  Vytalize provides an all-in-one solution including value-based incentives and smart technology that enables small and large independent practices to be successful in value-based care arrangements. Today, the company leverages this dynamic approach to support physicians caring for 130,000 senior patients. Last year, Vytalize acquired patient communication company MedPilot to allow them to manage the last mile of patient engagement.

The company is now integrating the rest of the downstream network, including hospitals, specialty networks, ancillary providers, and digital health companies, to streamline the delivery ecosystem from end to end. The company will use the new capital to continue investing in its care delivery infrastructure, partner with Medicare Advantage and commercial plans, and expand its team.

Recent Growth

Vytalize Health has grown its patient base 150% year over year and is now partnered with 280 primary care practices across 16-states. The company’s all-in-one, vertically integrated solution for value-based care delivery is responsible for $2 billion in medical spending. The company is expanding into new markets while increasing the concentration of practices in existing ones and has begun contracting with regional and national Medicare Advantage plans.

“Our goal is to strengthen the special relationship between patients and their primary care doctors, which becomes the foundation for realizing the full potential of value-based care,” said Vytalize Health CEO Faris Ghawi. “We’re witnessing new frontiers that were previously unimaginable in healthcare, and we’re excited to enable our doctors to be at the cutting edge of this next chapter.”

What You Should Know:

– Today, Signify Health announced it has reached an agreement to acquire Caravan Health, a leader in enabling accountable care organizations (ACOs) to succeed in value-based care payment. Together, the companies form one of the largest networks of at-risk providers in the U.S. 

– Together, Signify Health and Caravan Health will be better positioned to enable organizations to manage larger populations covered by value-based arrangements and to drive more coordinated clinical and social care across the healthcare continuum.

Post-Acquisition Impact

The combined companies’ contract with more than 3,200 health systems and physician group practices and 10,000 primary care physicians to cover more than 500,000 lives with approximately $10 billion total medical spend under management. Beyond Signify’s current network of over 3,000 physician practices and facilities contracted in value-based arrangements, Caravan adds more than 200 health systems and 100 Federally Qualified Health Centers with more than 10,000 primary care providers that collectively manage over 500,000 patients, most of whom are medically underserved and struggle to access care.

As part of the acquisition, Lynn Barr, Founder and Chairwoman of Caravan Health, will become Chief Innovation Officer of Signify Health. Tim Gronniger, CEO of Caravan Health, will become Executive Vice President, Accountable Care, Signify Health and CEO of Caravan Health, a Signify Company. Caravan Health’s approximately 160 employee population will transition to Signify Health, employing a combined total of 2,160 employees.

“A strategic focus for Signify Health has been driving more participation and success in value-based payment arrangements in alignment with our commercial payor clients. This focus also supports critical imperatives from the Centers for Medicare & Medicaid Services (CMS) to improve health equity and have everyone in Medicare fee-for-service aligned to an accountable relationship by 2030,” said Kyle Armbrester, CEO of Signify Health. “We are thrilled to welcome Caravan Health’s team as we build the infrastructure and payment models that are needed to achieve patient-centric, holistic care and better outcomes for everyone, especially the underserved.”

Financial details of the acquisition were not disclosed.

Value-based care (VBC) is finally gaining steam among healthcare organizations as executives look to implement processes that boost patient outcomes and rein in elevated levels of spending. To that end, more than 90% of health system executives say they expect VBC contracts will continue to grow in the coming years. 

Despite the widespread popularity of the concept of VBC, making it work is something of an “all-hands-on-deck” approach. VBC relies on the collaboration between many stakeholders across the industry, which presents a complicated challenge.

There are three key components to a successful VBC network: 

1. A robust infrastructure that supports the complex hierarchies of the healthcare ecosystem, that supports complex healthcare data needs, and can be shared and accessed by numerous participants

2. The ability to support numerous and evolving payment methodologies related to VBC

3. The inclusion of nonmedical and community-based organizations (CBOs) to address the social determinants of health (SDOH) that can lead to costly emergency room visits and hospital admissions

A strong VBC network will often need a sizable technology investment to revise traditionally siloed capabilities, the ability to cater to a spectrum of stakeholders, including accountable care organizations (ACOs), bundled payment programs, full and partial capitation, and the Medicare Shared Savings Program with upside and downside risk. Additionally, it should be noted that while CBOs are a critical part of this operation, many have slim budget margins and little to no funding for digital technology to improve efficiency and expand capacity.

Considering these factors, healthcare’s focus shifts toward Value-Based Administration (VBA).

Understanding VBA’s role

Currently, both payers and providers struggle to efficiently administer value-based arrangements at scale. Yes, they may have investments in existing claims and clinical workflow-based legacy technology, but they lack the ability to manage a complex care network involving multiple stakeholders in differentiated roles while accommodating the requirements of rapidly evolving value-based payment models. Additionally, the implementation of VBC contracts can take different forms, leading to spreadsheet reconciliation processes that lack timeliness.

How leaders should approach the task at hand is by extending those critical legacy systems. Luckily for them, VBA does just that by encapsulating purposefully flexible hierarchical partner models, scalable operationalization of contracts, and data sharing capabilities necessary to execute on value-based programs. 

Though so many healthcare stakeholders rely on data analytics and digital tools for network management, care coordination, and care delivery, they are simply not enough. Oftentimes, these point solutions can lead to more silos of information, which make it difficult to share with other partners and contribute to inefficiencies that impact outcomes and costs. Few organizations are willing to throw out everything and start over, given the substantial investment they’ve made in legacy information technology (IT) infrastructure and workflow.  However, these investments either cannot administer or cannot scale these arrangements.

This is where VBA enters the picture to enable VBC networks to facilitate whole-person care. VBA simultaneously orchestrates medical and nonmedical care delivery resources and services to drive better patient outcomes and lower healthcare costs. When deployed comprehensively, VBA cuts across all care settings with data capture and permissioned data sharing, including management of funding pools and risk arrangements, and does so at scale.

Currently, industry stakeholders continue to operate under a mix of Fee for Service (FFS) and value-based payment models. This is despite a recent announcement by the Centers for Medicare and Medicaid Services indicating a trend toward payment model simplifications.

These payment models range from solely FFS to FFS including incentives for reducing gaps in care, to shared upside and downside risk (or both), to full or partial capitation to downstream partners. Additionally, a white paper published in 2021 shows that FFS “with no link to quality or value, still accounted for nearly 40% of all insurer payments, and the majority of payments in Medicaid and commercial insurance.”

Providers and payers, who were already managing multiple payment models, are now also dealing with the fact that they must handle the health inequities hampering the healthcare system; this realization was brought into sharper focus during the COVID-19 pandemic. This makes SDOH data crucial to identifying factors such as housing security, income level, and access to transportation that exacerbate health inequities. 

However, a VBA process empowers payers and providers to collaborate with CBOs in a VBC network to share information, execute specific services, and coordinate patient care plans. This holds every partner in a VBC network, medical and non-medical/CBO, accountable to deliver on their expected value.

VBA in action

VBA coordinates the “many to many” relationships between VBC stakeholders and their ecosystem attributes to enable data capture and sharing, full execution of required financial arrangements for partners upstream and downstream, as well as necessary B2B and B2C multichannel communications. 

These partners may include health insurance carriers, risk-bearing entities like ACOs, clinically integrated networks, and carve-out programs from chronic disease management. Additionally, other partners may be primary care physicians, care management programming, social services networks, and community-based service organizations.

Another core capability of a VBA approach is the upstream capture of funding pools followed by downstream distribution to VBC network partners. This is conducted in alignment with the wide range of disbursement models in play within a given network. 

For example, a healthcare organization could transfer money to a home-dialysis provider for full payment after documenting receipt of the required post-visit status report for a patient, while also paying a Meals on Wheels community worker upon gathering confirmation of food delivery for the same patient. High-performance VBC networks enable both medical and non-medical resources to fulfill their respective roles within a diverse plan of care while using the same technology rails. This administrative approach improves outcomes, lowers costs, and creates greater efficiencies.

VBC is transforming healthcare as a whole: using a comprehensive, proactive approach that incorporates SDOH and leverages these services provided by CBOs. But to effectively implement VBC, it is essential that both providers and payers manage complex contractual relationships between network partners to ensure that all participants are paid accordingly. A keen focus on VBA is the driving force to make it happen.

About Lynn Carroll & Rahul Sharma

Lynn Carroll is the chief operations officer and Rahul Sharma, chief executive officer, of HSBlox, which assists healthcare stakeholders at the intersection of value-based care and precision health with a secure, information-rich approach to event-based, patient-centric digital healthcare processes – empowering whole health in traditional care settings, the home and in the community.  

What You Should Know: 

– Following the National Association of Accountable Care Organizations (ACOs) announcement of 2020 data detailing the Medicare Shared Savings Program (MSSP), Medicare’s largest alternative payment model, Bamboo Health, formerly Appriss Health and PatientPing, announced its national network of ACOs generated over $1 billion in total shared savings. 

– Bamboo Health’s ACO partners succeed under value-based care programs like the MSSP by utilizing their Pings solution, which provides real-time visibility into patient admission, discharge, and transfer (ADT) care events. This allows ACOs to identify high-utilizers, monitor post-acute length-of-stay, and apply timely interventions to reduce emergency department to inpatient conversions. 

– Through Bamboo Health’s actionable insights across the entire continuum of care, ACOs and community care providers can tap into patient ADT information to improve care quality by supporting safe care transitions and greater visibility into post-discharge referral patterns.

What You Should Know:

– Humana Inc. announced that it has signed a definitive agreement to acquire integrated post-acute care provider One Homecare Solutions (“onehome”) from WayPoint Capital Partners (WayPoint), the private equity affiliate of a New York-based family investment office.

– The acquisition will further advance Humana’s strategy to build a value-based home health offering.

– Founded in 2013, onehome is a provider of a variety of home-based services, as well as a convener of home health services stakeholders and a care and risk manager.

Acquisition will Enable Humana to Deliver National Value-Based Home Health

onehome’s model creates one integrated point of accountability that coordinates the needs of patients, physicians, hospitals and health plans for home-based patient care. onehome currently manages a range of post-acute needs including infusion care, nursing, occupational therapy, physical therapy and durable medical equipment (DME) services at patients’ homes, as well as appropriate site of care placement through its skilled nursing facility (SNF) at home programs.

The acquisition of onehome aligns with Humana’s recent announcement to fully acquire and integrate Kindred at Home, and provides a number of key capabilities that will enable Humana to more effectively deliver value-based home health at a national scale:

– onehome has significant experience with risk-based contracting, and has fully-capitated models in place in Florida and Texas that will provide valuable insights for the expansion of similar contracting in other states.

– onehome has developed fully-dedicated network management and utilization management systems that can create greater efficiencies for the administration of in-home patient visits.

– onehome owns and manages home-based DME and infusion services for members in its core geographies that can be expanded to other markets and deliver more simplified coordination of these services for patients and providers.

– onehome’s ownership of DME services can deliver greater value and better outcomes through reduced waste and more consistent equipment utilization by members.

“At Humana, we are implementing a strategy to build a new Value-Based Home Health model that will improve patient outcomes, increase satisfaction for patients and providers, and provide greater value for health plan partners,” said Susan Diamond, Segment President for Humana’s Home Business and Humana’s Interim Chief Financial Officer. “The acquisition of onehome is a key component of that strategy. It complements our recent announcement to fully acquire and integrate Kindred at Home, and brings together additional capabilities that will allow Humana to deliver value-based home health at a national scale. By combining onehome’s value-based approach with Kindred’s home health services and Humana’s analytical capabilities and clinical expertise, we believe we can create a transformational value-based offering to serve more people, including non-Humana plan members, nationwide.”

What You Should Know:

– Elevate Health, a Washington-based nonprofit Accountable Community for Health (ACH) organization, has partnered with us to leverage the Innovaccer Health Cloud to strengthen care management and improve patient outcomes. It was challenged to integrate data from disparate sources and close gaps for hundreds of patient records.

– With the Innovaccer Health Cloud, Elevate Health saved $6M in care costs and redefined its care management model with valuable outreach strategies and interventions by implementing evidence-based workflows on Innovaccer’s platform to automate routine tasks.

Population Health Stratification Toolkits

Elevate also built a comprehensive, data-agnostic ecosystem with a broad population health stratification toolkit to improve patient outcomes. It leveraged more than 100 integrations to multiple digital health services and an extensive collection of intelligent APIs with cost, quality, and utilization metrics to gain insights into its network performance. The care teams also leveraged the smart worklists to coordinate schedules and obtain an overview of patients’ health conditions to determine the need for screening, treatment, and follow-up.

“We’re passionate about improving physical and economic health in our communities through innovation,” said Alisha Fehrenbacher, FACHE, CEO of Elevate Health and OnePierce Community Resiliency Fund. “Partnering with Innovaccer has been one of the biggest aspects of our broader care management approach to advance a collaborative, whole-person health model. Innovaccer’s tools help our provider network to deliver coordinated care and measure regional health outcomes.”