Payment Models Succeed When The Right Data Moves

By Robin Trush and Susan Clark

Healthcare’s value-based payment (VBP) models are here to stay….and grow in scale.  Data interoperability matters for patients and for successful execution on the model.  VBP ties reimbursement to outcomes, efficiency, and patient experience requiring organizations to seamlessly access, exchange, and use data across the entire care continuum.  And THAT well-known definition can be actualized through dedicated interoperability efforts allowing for more of the care delivery system to access needed information from one another.  These entities include medical, behavioral health/ substance use disorder (BH/SUD) providers and organizations that address health related social needs (HRSN). 

Fundamentally, treating and supporting a person through a holistic lens tie together the facts and drivers of an improved health pathway.  Historically, interoperability efforts have been focused solely on standard medical information and in some communities, public health data.  Recent advancements to address social determinants of health (SDOH) has now begun to move actualizing “whole person care” just a bit, but there is still a chasm worth of data to truly practice and administer it.  Most states and regions are still lacking in critical data points;  behavioral health and substance use information.  While complex privacy concerns have been a primary driver of those gaps, new federal requirements to allow for ease of data sharing have arrived. 

Interoperability can and does allow for better patient experience along with bending the cost curve.  How does that happen?  By allowing for a complete, real-time picture of the patient not just the data inside coming from a single EHR or delivered by a single professional.  Interoperability inclusive of all relevant patient information can provide a treatment professional access to medical, BH/SUD treatment history and status, medications and other social care data such as housing , food access gaps or transportation needs.  Having all of those points impacting a health profile allows for accurate risk stratification and predictive analytics along with earlier identification of care needs, both of which are key VBP metric tools.  Without shared data, risk scoring is inaccurate, care plans are incomplete, and performance metrics suffer.

Often overlooked in patient care satisfaction, outcomes and cost drivers is transition of care gaps.  These moments take place when an individual moves from one care team to another, one setting to another, or during an episode of care involving multiple provider types.  This is especially true for individuals with complex needs served by multiple specialty providers and the BH/SUD system, which can often span extended periods of time.  Practitioners, therapists and case managers can all support transitions of care better through use of a full patient data set.  Without this view, emergency room visits take place, patient care may be duplicated or even provided inappropriately, and additional medical costs are incurred, which may not improve overall care outcomes. 

Value based payments are not as widespread in the BH/SUD arena today.  While HEDIS measures have been used in certain markets, many challenges have plagued this domain.  These have included a lack of a compliant patient consent method, specialty payor attribution and varied opinions on standard outcome measures.  Additionally, value-based models depend on data-driven insights, and without access to interoperability technology the entire medical community, including BH/SUD providers will not have a place to see a unified data set.

A real world example comes from a national study commissioned by the Office of the Assistant Secretary for Planning and Evaluation and conducted by HIMSS, which examined organizations already operating in value based arrangements. Providers who shared clinical and claims data through interoperable systems were able to see patient encounters across multiple settings instead of relying only on what lived inside a single EHR. With this shared view, care teams identified gaps earlier, reached out proactively, and reduced unnecessary or duplicative services. One home visit network summed it up simply: they were not changing how clinicians practiced, they were giving them the information they needed to act sooner. That access improved care coordination, sharpened risk stratification, and boosted performance on key VBP measures like readmissions and follow up care. It is a clear example of how integrated data directly influences outcomes, patient experience, and total cost of care.

Here is the call to action, and one that is achievable.  Interoperability technology exists in the form of HIEs, HDUs, national databases and the like.  The need for holistic data is clear, and the operational practices to do this can be actualized. 

You may be thinking, “Great. But how?”  The plan to operationalize this in both states and local regions must have a strategy that includes multi-perspective input from technical to legal to clinical to finance. This strategy will start with data asset inventories, technical capabilities assessment, and a prioritized roadmap to get there that is prioritized by bite-sized, most common use cases. Bring your champions to the table to bring to light workflow considerations and who are willing to believe that whole person data sharing is a future reality. 

This work is often daunting and may have been deprioritized by organizations including technology entities, based on barriers that no longer exist.  The time to invest has come.   The need for a healthier patient trajectory along with total cost of care reductions is smack-dab here.