How direct-contracting initiatives can power employer-funded health plans – BenefitsPro

The execution of whole-person care plans must occur across networks of care where both medical and non-medical resources are tightly coordinated.

The COVID-19 pandemic exposed and exacerbated system health equity issues that have long plagued underserved communities. Vulnerable populations have been severely impacted by the pandemic, resulting in higher hospitalization and death rates among African and Hispanic Americans, according to the Centers for Disease Control and Prevention (CDC).

Employers, community advocates, and the public health sector are becoming increasingly aware that implementing genuine value-based care (VBC) initiatives – to improve patient outcomes while reducing health care costs – will be difficult without also addressing issues of diversity, equity, and inclusion (DEI) in the health care ecosystem.

Unlike traditional fee-for-service health care, VBC is about proactively keeping people healthy rather than engaging in reactive “sick care.” The holistic nature of VBC requires the ability to leverage social determinants of health (SDoH) to develop individualized care plans and to inform population health strategies. VBC models that incorporate SDoH to promote health literacy and support DEI values can achieve greater health equity, better patient outcomes, and lower health care costs.

Related: 3 strategies for employers considering value-based insurance design

Yet VBC is heavily dependent on sharing data with community-based organizations (CBOs), including social service agencies, charities, foundations, and religious groups. CBOs possess SDoH data regarding environmental and social factors (such as income level, housing status and access to healthy foods), which research shows have an 80% impact on a person’s health.

With SDoH data, employers and their administrative partners can adopt a holistic approach to the health of their employees and their families. Even if an employer would like to efficiently administer value-based programs at scale, legacy administrative systems can make this impractical. One common barrier is the inability to onboard and manage a complex multistakeholder care network while accommodating the event-driven and episodic requirements of payment models that no longer are claim-centric. Another barrier is the timeliness and digitization of complex data reporting and the inability to prospectively understand contract performance, rather than after the fact.

A framework that supports the complex many-to-many hierarchies between entities in the network is needed. These relationships become important not only for stakeholder onboarding, complex data capture, digitization and sharing, but also to administer payments between entities.

By designing and implementing a value-based benefits administration (VBBA) model that incorporates health at the “edge” – that is, reaching patients in the home and in the community, both physically and through digital technology – employers can more effectively address the wellness needs of vulnerable populations while better managing costs and tracking contract performance.

Successful VBBA requires a network infrastructure that enables the many-to-many relationships between VBC stakeholders and their counterparts. These may include health insurance carriers and third-party administrators (TPAs), risk-bearing entities such as accountable care organizations (ACOs), clinically integrated networks, carve-out programs for chronic disease management, primary care, care management programming, social service networks, and CBOs.

Administration of direct contracts can be a tremendous challenge using traditional approaches and legacy systems that lack the hierarchical relationship structures necessary for onboarding stakeholders in value-based contracts. This hierarchical approach to partner onboarding, scaling of contract operationalization, and permissioned data sharing is a necessity for alignment of medical, social, behavioral and environmental components of successful value-based program administration and high-performance networks that successfully deliver on healthy patient outcomes.

A network of networks

The execution of whole-person care plans must occur across networks of care where both medical and non-medical resources are tightly coordinated within an infrastructure that aligns performance for healthy patient outcomes and financial risk management. By providing ecosystem participants with a solid onboarding model and the right supporting capabilities, employers and their TPAs can successfully execute value-based programs that incorporate whole health.

These emerging care and payment models demand real or near real-time status and data exchange, a more prospective approach to reimbursement, and precision approaches to care team data sharing. Further, by engaging and integrating the patient across the continuum of care, employers will empower patients to be effective stewards of their own health.

While the transition won’t happen overnight, every entity involved in providing care to the patient eventually will become a part of the networks that provide VBC. A network essentially is comprised of the providers, facilities, suppliers, and caregiver organizations with which a health insurer or employer has contracted to deliver health care services to patients. When an entity in a network is engaged in several networks with different contractual engagements with other entities, it creates very complex many-to-many relationships.

A network of networks is possible only with an infrastructure that supports both the complex hierarchies between the entities involved in VBC and the data infrastructure. 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.

Employers and their TPAs can take advantage of such a robust data/microservices/hierarchy support infrastructure that facilitates a faster move to expand direct contracting and VBC programs. This platform infrastructure can extend the capabilities of the TPA to integrate the data layers seamlessly, then extend that data layer either as a DaaS or as a PaaS (Platform as a Service).

Real-time health care requires an aware and adaptive technology infrastructure that supports complex relationships and datasets for the network and enhances those by using publicly available datasets.

Employers are getting directly involved in demanding accountability for health care costs and the promotion of wellness. Supporting the hierarchical needs between the different entities involved in value-based networks, coupled with the data and microservices infrastructure discussed above, will accelerate the adoption and scaling of VBC and allow employers to improve health outcomes while lowering care costs.

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

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