By Rahul Sharma and Lynn Carroll
It was clear even in the early months of the COVID-19 pandemic that the coronavirus was disproportionately impacting vulnerable populations, leading to higher hospitalization and death rates among Black and Hispanic Americans. While COVID-19 itself was a sudden and deadly global health crisis, the pandemic also exposed and exacerbated systemic health equity issues that have long plagued underserved communities.
Providers, payers, community advocates, and the public health sector increasingly recognize that implementing value-based care (VBC) will be difficult without also addressing issues of diversity, equity, and inclusion (DEI) in the healthcare ecosystem. Unlike traditional fee-for-service healthcare, VBC is about proactively keeping people healthy rather than engaging in reactive and more costly “sick care.” This requires a “whole-person” approach that leverages social determinants of health (SDoH) to develop individualized care plans and inform population health strategies.
SDoH include environmental and social factors such as employment status, income level, education level, housing security, physical activity, neighborhood safety, and access to healthy foods. Research shows SDoH have as much as an 80% impact on the health of an individual or population. Additionally, studies have confirmed a link between SDoH-related risk factors and chronic diseases (such as hypertension and diabetes), which together account for 90% of healthcare spending in the U.S.
VBC reimbursement models that integrate and interpret SDoH to promote health literacy and support DEI values can achieve greater health equity, better patient outcomes, and lower healthcare costs. However, VBC relies on sharing data with community-based organizations (CBO), including social service agencies, charities, foundations, and faith-based groups. With SDoH data, providers and their administrative partners can adopt a holistic approach to patient care.
Supporting hierarchical relationships in a framework
Integrating CBOs into VBC networks requires a framework to support the alignment of medical and community resources. A value-based benefits administration (VBBA) model that incorporates health at the “edge”—reaching patients in the home and in the community, both physically and through digital technology—can enable providers to more effectively address the wellness needs of vulnerable populations while better managing costs and tracking contract performance.
VBBA requires a network infrastructure that enables the many-to-many relationships between VBC stakeholders. These may include health insurance carriers and third-party administrators, risk-bearing entities such as accountable care organizations, clinically integrated networks, primary care, carve-out programs for chronic disease management, care management programming, social service networks, and CBOs. This network infrastructure enables payer and provider VBC collaborations to administer funding methodologies that incentivize wellness and empower patients with access to community resources.
Administration of CBO direct contracts can be a formidable challenge using traditional approaches and legacy systems. However, a hierarchical approach to payer, provider, and community stakeholder onboarding that supports varied funding methodologies can streamline contract operationalization. It also can foster permissioned data digitization and sharing necessary for aligning medical, social, behavioral, and environmental components of value-based programs and high-performance networks that improve patient outcomes.
Seamless integration of data layers
Whole-person care plans must play out across networks with infrastructures that tightly coordinate medical and non-medical resources, aligning performance for healthy patient outcomes and financial risk management.
These emerging care and payment models demand near-real-time status updates and secure permissioned data exchange, a more prospective approach to reimbursement, and precision approaches to care team data sharing. Further, by integrating the patient across the continuum of care, providers will empower patients to be effective stewards of their own health.
While the transition won’t happen overnight, every entity involved in patient care eventually will become a part of the networks that provide VBC. These providers, facilities, suppliers, and caregiver organizations will have different contractual arrangements with payers and employers, creating complex many-to-many relationships across networks.
A network of networks is possible only with an infrastructure that supports the complex hierarchies between VBC entities and the merging of structured and unstructured data sets so that they can be queried properly to glean information and make good decisions. Interoperability between these networks as well as legacy systems is possible only with a proper DaaS (Data as a Service) layer built on top of the data infrastructure.
Providers can take advantage of such a robust data/microservices/hierarchy support infrastructure to facilitate the expansion of VBC programs. This platform infrastructure can extend existing investments to integrate the data layers seamlessly, then extend that integrated layer as either a DaaS or PaaS (Platform as a Service).
Aligning different sources of funding with provider VBC contracts and enabling CBO participation and communication with medical resources requires a robust and adaptive technology infrastructure. This infrastructure must support complex relationships and data sets for the network, including the use of publicly available data sets.
Providers increasingly are being held accountable—and rewarded—for reducing healthcare costs and promoting wellness. By supporting the hierarchical needs between the entities involved in value-based networks, coupled with the data-and-microservices infrastructure discussed above, providers can accelerate the adoption and scaling of VBC to boost outcomes, stretch the healthcare dollar, and improve the patient experience.
Lynn Carroll is the chief operations officer and Rahul Sharma is the CEO 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.