From Silos to Services for Value-Based Care

The evolution of health care IT systems seen by industry visionaries sounds great. Siloed clinical and insurance systems get connected and can work as one. Information-rich processes flow smoothly and securely over connected services that span care settings, providers, and payers. We gain leaps in efficiency and accuracy of care coordination, snapping clinical and payment services together like the related pieces of the health care puzzle that they are.

At a practical level, health care professionals are asking what “interoperability” really means? How close are we today to that vision of tomorrow?

Good questions. Our industry has made astonishing gains, and we are fast approaching a time when nearly all payment incorporates measures of value, with payers now 58 percent and hospitals now 50 percent along the continuum to full value-based reimbursement (VBR).

These new payment models require providers and payers to collaborate as never before, but the clinical and financial systems we need to make the best decisions and fully automate complex reimbursement models remain siloed. To make VBR work, we must achieve interoperability at scale — and that means across payer, provider, and vendor lines.

That’s a tall order for an industry that hasn’t always had the technical standards to define how systems should work together.

I was fortunate enough to see and experience the impact of interoperability early in my career, long before “interoperability” was a buzzword. In 1991, I joined a transplant team at an academic medical center in a newly defined role: “transplant insurance coordinator.”

In those days our team faced a challenge common to health care professionals everywhere. Once our physicians decided on a particular care path, our transplant patients needed to be treated quickly, but securing authorizations from insurance providers was time-consuming.

As the new insurance coordinator, my job was to help facilitate that process. We quickly discovered that we needed a way to align insurance information with clinical information in order to process approvals more efficiently.

Our solution was to build a database that integrated benefits, coverage limits, and referral information. We began to see patterns in referrals, utilization, approval patterns, and the administration of benefits that gave us the ability to drive process improvements and reduce costs.

For example, insights into referral patterns helped us establish a network of physicians with the expertise, qualifications, and capabilities to work with transplant patients, which helped us negotiate “case rate” contracts with insurers.

The network information was also shared with the care team and patients, ensuring care was coordinated and could be more cost-effective because they stayed in the program.

Today, that type of contract for an episode of care would be called a bundled payment arrangement. We revealed clinical and financial insights that helped improve the quality, cost-effectiveness, and administrative efficiency of the care we provided our patients.

One thing quickly became clear: This was how clinical care should work for every patient in every subset of medical need. But a quarter century ago, most of the data entry and analysis had to be done manually across our network of care settings and physicians.

That challenge was compounded by a larger problem. Every system and function we worked with was a stand-alone silo that couldn’t be connected to anything else. Likewise, our clinical research group used multiple worksheets to track patient information and manually enter data into a separate research database — but they weren’t connected to the system nurses used to record data in the hospital record.

Now, much of the information payers and providers work with today is digital, and the workflow and processing are automated. But there’s still an issue: We have digitized massive amounts of information and automated complex processes that remain largely locked in traditional silos.

To see how interoperability facilitates value-based care and reimbursement, consider the rapidly rising use of bundled payment models today and the challenges payers and providers alike face in designing, contracting, implementing, scaling, and analyzing them.

What has changed from the past is our ability to solve them through HIT automation and, increasingly, interoperable solutions. Such contemporary, interoperable systems are the only way to unlock silos and unleash value for an industry moving to value.

Let’s say a physician determines a patient needs a knee replacement. That diagnosis and order would be introduced into the hospital’s EHR system and would automatically generate all the medical necessity information.

That information would be instantly transmitted to the payer and run through their authorization process, using an exception-based utilization management model. If it meets authorization, that approval information would bounce back to the clinician within minutes

The clinician or care team can then inform the patient which centers do knee replacements as part of the bundled payment arrangement, to help minimize or eliminate the patient’s out-of-pocket expense. Meanwhile, the payer would have automatically received a notice that one of its members is going to get a knee replacement. Incoming claims would be automatically parsed, processed, and paid as part of the bundled payment arrangement.

In the end, one bill would be automatically moved through the system. This would happen because the payment side was automated and connected. That’s how the payer would know who’s part of the program, who’s not, what’s the reimbursement, and how to automate the payment accurately.

That’s how medical policy, payment policy, value-based reimbursement models, provider management, and contract management could be automated to unlock immense value now trapped in information and automation silos. Payment could be faster, more accurate, and more aligned to clinical guidelines.

The time has come to tear down the silos. It is crucial that our HIT systems be capable of collaborating digitally just as payers and providers collaborate in the real world. Let’s start unlocking and integrating the clinical and financial data and processes we need to make the best decisions and help automate reimbursement models end to end.


Amy Larsson is vice president for clinical claims management at Change Healthcare.

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