Will Be On Data In The Emerging Era Of Value-Based Models Of
Despite the continued prevalence of the
traditional fee for service reimbursement models as the primary method
of payment, over time healthcare reimbursement will "give way" to
value-based models of reimbursement.
But, for a value based reimbursement model to be
developed and succeed, it will require a fair amount of data, according
to a leading expert on payor and provider contracting.
"We believe that integrated delivery systems that
have access to hospital data, ancillary department data and outpatient
data are going to be the best suited organizations to be able to help
define what episodes of care funding should be," said Russell Foster, a
principal with pmpm Consulting Group.
Providers will require that level of data for the
matching of revenues and expenses to make sure thatthe reimbursement
which is received under such a model is equitable and covers the cost
Russell also believes organizations that are not
integrated and do not have access to the data in those hospital records
are "going to be put in a position of needing to align with partner
hospitals and with other providers and ancillary providers to be able
to attract and gather the data elements that are needed to be able to
understand and define what a case rate might be or a bundled payment
amount might be to be successful."
He also acknowledged that inherent in this are the
legal issues surrounding the sharing of data when "you have disparate
organizations that are not otherwise aligned."
The question of privacy and access to the data is
going to be an issue and should be reviewed by attorneys to determine
how that might be improved, he added.
It will be difficult to end up with an
all-inclusive case rate that includes inpatient claims, outpatient
claims, and ancillary claims, if providers cannot access the data
elements needed to define what those costs should be.
Positioned For Performance Measures
"It’s also true that in an integrated
delivery system, the organization is probably better prepared and
structured to redefine performance measures and guidelines to institute
care management systems that are needed to be able to operationalize
some of these payment reform models," Russell said.
Demonstrating value to an employer is going to be
especially important, Foster said, as the industry goes through this
evolution. "It’s pretty clear that employers need payment
Employers need lower premium costs to continue to
cover their employees and dependents. And, they also need healthier
employees, who stay at work, who have fewer absences or illnesses. It
is going to be "incumbent on health providers to demonstrate to them
that they have a quality and efficient program, and that the providers
can deliver that type of care in a cost-effective environment."
If organizations are not in a position to
demonstrate the value proposition, it will be difficult for them to
hold their membership over time, Foster warned.
Foster made his remarks during a recent audio
conference on managed care contracting, "Managed Care Payor-Provider
Contracting: New Directions, Risks and Strategies," sponsored by the Managed
Care Information Center. A
CD-ROM of the program including all slides and handout materials is
available. For more information, visit www.healthresourcesonline.com/edu/mcc09.htm
Address: pmpm Consulting Group, 1425 River Park
Drive, Suite 230, Sacramento, CA 95815; www.pmpm.com.