The shift from fee-for-service to value-based care has created some challenges for the healthcare industry, such as keeping costs down while improving the care experience. The dialogue is also changing from the health plan perspective, as providers work to make those quality measures.
For HealthEdge Chief Nursing Officer Kim Ingram, data holds the key to making value-based care possible. Not just having the data, but incorporating it into the clinical workflow to inform those decisions.
“We’re seeing how the model of care is changing,” Ingram said. “Data is perhaps embedded into the plan or system, and then delegated out to providers.”
Ingram’s team faces the challenge of fueling data exchange between providers and payers -- as well as those people who support those roles -- “to drive the clinical experience.”
This need for data exchange becomes increasingly important as Centers for Medicare and Medicaid Services Administrator Seema Verma continues to make the push for fewer regulations. Ingram explained it’s crucial for hospitals and health plans to engage at the point of service and care.
“It’s really around a healthcare provider-plan collaboration,” said Ingram. “They are the ones driving the decisions and costs.”
So the question really becomes, “how do you give them the data to make better decisions?” Ingram said.
The right information will improve systems, benefits, resources and overall care. Not only that, but it can help payers target best-in-class facilities.
“It really extends that point of care reach,” said Ingram. “but you have to provide the right amount of data: the right information to help providers make good choices. Ultimately, we ask, is the individual getting the right care at the right time? And how do we engage in clinical decision making?”
Adding to the challenge, according to Ingram, are patients who are “better informed,” based on internet research of their symptoms, the best course of action and even the best provider.
“We call that ‘internet-positive,’” said Ingram. “They come in and it’s a different dialogue than before. They’re wanting a specific treatment, but providers have to be able to show their reasoning from a quality perspective.”
Not only that, those patients are often in an emotional state and haven’t contacted the health plan to determine coverage, said Ingram. “So it’s about providing that quality and metrics data to drive decision-making.”
For Ingram, who comes from a clinical background, providers need to find the best course of action for the patient, as “it’s the individual that’s actually going through the experience.”
“The question is really, how do we enable people to make the right choices,” said Ingram. “My philosophy is the voice of the customer: What are we really understanding about them? What’s the right thing to do and the right way to do it?”
“And how do we give that data to [payers and providers] in a way to enable those decisions?” said Ingram. “We have to make our software enable them to be able to serve, provide information, approval, and recommendations -- based on completing both cost quality and outcomes. And sometimes those are hard conversations.”