Month: June 2023

In the realm of healthcare, the transition to value-based care has become a crucial goal for both payers and providers. Value-based care focuses on improving patient outcomes while reducing costs, shifting away from traditional fee-for-service models. To effectively evaluate performance in value-based care arrangements, access to accurate and timely data is essential.

Even though payers possess a wealth of data that can provide valuable insights into healthcare outcomes and costs, the sheer volume of data can be overwhelming. Payers often struggle to extract meaningful insights due to the terabytes of siloed data they collect across their enterprise and outdated analytics solutions that cannot handle the complexities of performance-based arrangements.

Bridging the Data Gap

While the management and reporting of data for traditional measures have made progress, value-based contracting presents unique challenges. Value-based contracts are often complex and vary in nature, requiring customized infrastructure and data management systems.

Modern technology solutions, like those provided by HealthEdge, are designed to handle diverse data types, such as fee-for-service and value-based data, and they can help payers more effectively evaluate their performance across measures such as Healthcare Effectiveness Data and Information Set (HEDIS) and STAR ratings. HealthEdge solutions enable accurate pricing, continuous performance comparison between providers, and transparent reporting to establish a balanced and collaborative relationship between payers and providers.

One of the significant barriers to effective value-based care is the asymmetry of information between payers and providers. Payers often have access to extensive data that providers lack, which can create a sense of uncertainty and fear among providers during contract negotiations.

To foster trust and encourage provider participation in value-based contracts, the flow of information must be balanced. Miscommunication and roadblocks can hinder effective collaboration and limit the progress of value-based care initiatives. Providers may view value-based care as a potential financial risk, which creates resistance and a perception of being taken advantage of. The accurate and timely flow of data supports the development of mutually beneficial relationships and an open dialog.

Payers need to provide transparent insights to providers regarding their performance, patient gaps in care, and financial implications. By doing so, providers can make informed decisions and actively engage in collaborative efforts to improve patient outcomes and confidently pursue value-based care reimbursement plans.

Creating Transparent and Sustainable Arrangements

To overcome the challenges and facilitate the advancement of value-based care, payers and providers must come together to create transparent and sustainable arrangements. This involves fostering an environment of trust, open communication, and shared goals that come by leveraging accurate and timely data.

By embracing accurate and timely data, payers and providers can work together to improve health outcomes, enhance cost containment, and deliver positive member experiences – all common goals of the healthcare industry’s push towards a value-driven future.

To learn more about how your organization can better leverage data to advance value-based care arrangements with providers, visit www.healthedge.com.

 

The Evolution of Value-Based Care

While the term “value-based care” has gained popularity, its widespread adoption has been slower than anticipated. It essentially represents different contracting models beyond traditional fee-for-service reimbursement that aim to reduce costs and improve health outcomes.

The main challenge in expanding value-based care is getting both payers and providers comfortable with the uncertainty of reimbursements under these arrangements. Providers often struggle to shift from their fee-for-service mindset and adapt their business operations to take on financial risk. Payers are often unsure about how to best build and manage their care networks to achieve their value-based care goals while also meeting the needs of the populations they serve.

Building a partnership between payers and providers, based on transparency and information symmetry, is crucial for successful value-based care implementation.

The Role of Technology in Value-Based Care

Complex workflows, analytics for identifying gaps in care, and member risk stratification can be facilitated by modern care management systems. Digital tools and mobile infrastructure can empower members to be more engaged in their care, especially when they are outside of their traditional healthcare setting.

Technology can also help health plans tap into the vast amount of data they possess to evaluate performance across various measures, such as HEDIS and STAR ratings. It can also be used in predictive modeling for gaps-in-care analysis, which can help identify members at risk before they experience an adverse event.

Many health plans face challenges in consolidating data, analyzing it effectively, and presenting actionable insights from it. Modern technology platforms are needed to support value-based contracting, enabling accurate comparisons between providers on different payment models, and fostering transparency in the provider-payer relationship.

HealthEdge’s Contribution to Value-Based Care Success

HealthEdge offers modern technology solutions that support payers’ efforts to manage value-based care arrangements. HealthEdge products, such as HealthRules^® Payer, GuidingCare^®, and Source streamline claims management, adjudicate capitation arrangements, facilitate care management workflows, and improve payment integrity. The company’s Wellframe^® product enables digital care management, enhancing patient engagement and improving health outcomes. HealthEdge’s technologies aim to simplify healthcare processes, deliver real-time information, and improve overall member experiences.

At HealthEdge, we believe value-based care holds the potential to transform healthcare delivery and reduce costs. That’s why we are focused on helping the healthcare industry make progress against their value-based care goals by leveraging technology to provide real-time cost and benefit information to members and providers, resulting in greater transparency and better healthcare experiences.

To learn more about how HealthEdge solutions can help your better manage risk, streamline operations, and enhance member experiences, and pursue value-based care arrangements, visit www.healthedge.com.

In90group Research recently hosted a webinar with AHIP and HealthEdge to release findings from a new study of more than 100 health plan leaders regarding the current state of payment integrity and how health plans are approaching their payment integrity strategies for 2025.

Based on the data, it appears that health plans should consider a fresh approach to payment integrity across their enterprise to help tackle some of their long-standing and most frustrating challenges. The highly interactive webinar featured Ryan Mooney, EVP and GM, HealthEdge Source and Carl Anderson, Carl Anderson, Senior Product Manager HealthEdge Source sharing their perspectives on the data.

To watch the full webinar, click here: New Research In Payment Integrity Reveals a Paradigm Shift is Underway.

We’ve summarized the five key findings in this post.

5 Take-Aways From the New Research

1. Workforce Shortages and Limited Resources: A significant challenge faced by payer organizations is the limited availability of qualified resources to ensure accurate claims payment. The webinar revealed that 64% of respondents ranked limited resources as one of their top issues, preventing them from keeping up with changing fee schedules and policy updates. Additionally, 58% expressed difficulty in hiring and retaining qualified professionals for this complex work. These challenges may arise due to the manual labor involved in ensuring accurate claim payments.
2. Limited Visibility and Root Cause Issues: Another prominent challenge identified by payers is the limited visibility into third-party vendors and root cause issues. Without comprehensive visibility, payers struggle to identify the underlying causes of payment errors and address them effectively. This lack of insight leads to a cascade of problems, such as increasing workload and growing financial losses. Achieving transparency and identifying root causes are crucial for building effective payment integrity programs.
3. Manual Rework and Costly Errors: More than half of the respondents revealed that over 20% of their claims required rework, which incurs significant costs ranging from $25 to $181 per claim. The financial burden resulting from these errors extends beyond rework expenses and includes factors like provider dissatisfaction and member dissatisfaction. To address this issue, payers need to focus on getting claims right on the first attempt.
4. Misaligned Initiatives: While payment integrity initiatives involve multiple departments within an organization, misalignment often hinders their effectiveness. The webinar findings indicated that over half of the respondents felt that their organization’s payment integrity initiatives were at odds with other initiatives. This misalignment can be attributed to a lack of a common goal across departments, competing priorities, and stretched resources. Achieving a more holistic enterprise approach is vital for overcoming these challenges and ensuring a unified payment integrity program.
5. Misaligned Vendor Incentives: Many payers struggle with the burden of multiple third-party vendors, resulting in increased costs and complexities. In the webinar, the speakers highlighted the challenges faced by payers when using several editing tools stacked on top of each other. These challenges include maintaining multiple IT systems, managing conflicting content, and navigating fragmented workflows. Consolidating vendor relationships and adopting a single, unified platform can help reduce costs, streamline operations, and enhance efficiency.

The Path Forward: Technology as a Solution

Historically, technology has taken a backseat to content when it comes to selecting payment integrity vendors. However, the webinar highlighted a shift in focus, with technology emerging as a critical component in overcoming payment integrity challenges. Payers are realizing that technology can provide solutions and streamline processes that manual labor alone cannot achieve. By leveraging modern and flexible technology, payers can effectively tackle rising complexities and improve their payment integrity initiatives.

To address the challenges identified in the webinar, HealthEdge Source delivers a modern technology platform that gives payers the ability to access pricing and policy changes from a single place, thereby improving transparency and streamlining operations. By leveraging technology, payers can achieve greater control, visibility, and interoperability within their payment integrity initiatives. Additionally, technology empowers payers to reduce dependency on contingency vendors and address root cause issues, resulting in improved accuracy and savings.

To learn more about how Source can help your organization achieve its payment integrity goals, visit Prospective Payment Integrity – HealthEdge.

 

In today’s fast-paced environment, where data transfer is vital for efficient operations, HealthEdge recognizes the importance of providing high-speed connectivity options to its customers. While the standard VPN connection has served well in the past, it may not always meet the needs of customers requiring rapid and large-scale data transfers. To address this challenge, HealthEdge offers a dedicated point-to-point circuit, enabling superior performance, monitoring capabilities, and troubleshooting between HealthEdge and customer data centers. In this blog post, we will explore the market and business background of HealthEdge’s high-speed connectivity options, the associated benefits and differentiation, as well as how these solutions work.

A Bit of Background

Historically, HealthEdge’s software solutions have relied on VPN connections to connect with customer data centers. While VPNs have been effective for many customers, they do pose constraints when it comes to transferring large amounts of data quickly. HealthEdge now offers high-speed connectivity options to cater to the specific needs of customers with demanding data transfer requirements. By providing dedicated point-to-point circuits, HealthEdge ensures that customers can transfer data swiftly, enhancing operational efficiency and minimizing any bottlenecks that may arise from slower connections.

Top 5 Value Points of High-Speed Connectivity

HealthEdge’s high-speed connectivity options come with several significant benefits that set them apart from traditional VPN connections. Let’s explore some of these benefits:

1. Secure User Authentication: HealthEdge employs OpenID Connect and/or SAML2.0 protocols for user authentication. These protocols are industry-standard and provide a secure and open authentication framework. By leveraging SAML and OpenID Connect, HealthEdge enables customers to authenticate users via a secure Identity Provider (IdP) managed by the customers themselves. This approach ensures that sensitive credentials are only sent directly to the customer’s IdP, enhancing privacy and minimizing the risk of storing data within the application.
2. Payer Authentication Delegated to Customer’s IdP: HealthEdge’s high-speed connectivity options allow customers to apply their own password policies independently, without HealthEdge’s involvement. Additionally, by relying on the customer’s chosen IdP, which specializes in secure industry-standard authentication, the burden of implementing and maintaining advanced security methods rests with the IdP. This arrangement ensures that customer data remains safeguarded while benefiting from the economies of scale and expertise provided by the IdP.
3. Multifactor Authentication (MFA): HealthEdge supports the use of Multifactor Authentication as an optional layer of security. MFA requires users to provide two or more categories of authentication to verify their identity. This can include something the user possesses (e.g., a unique token from a third-party application) or something they are (e.g., a fingerprint or retinal scan) along with a standard user ID and password. By implementing MFA, HealthEdge adds an extra layer of security, ensuring that access to sensitive data, such as ePHI (electronic Protected Health Information), is limited to authorized personnel only. This aligns with regulatory requirements such as HIPAA compliance.
4. Just-in-Time (JIT) User Provisioning: HealthEdge’s high-speed connectivity options streamline user access management and identity governance. JIT user provisioning automates the process of managing users in the health plan’s system, saving time and reducing the workload for administrators. This efficient approach frees up valuable resources for other critical tasks.
5. One-Time Single Sign-On (SSO) Configuration: HealthEdge’s SSO configuration is a one-time activity. Once implemented, the same configuration works seamlessly across all of the health plan’s environments, including Production, Pre-Prod, UAT, Dev, and Test. This externalized configuration approach accelerates deployments and upgrades and reduces operational costs.

How it Works

To initiate the process, HealthEdge first assesses the best carrier option available in the geographic area. Based on this evaluation, HealthEdge will order a dedicated circuit from the chosen carrier. The dedicated circuit serves as the primary connection, enabling high-speed data transfer between HealthEdge and customer networks.

Once the carrier is selected and the circuit is ordered, HealthEdge provides the customer with connection details, including addresses and routing information. The customer is responsible for setting up a Layer 3 connection point within their data center. This connection point serves as the entry point for the dedicated circuit and facilitates the transfer of data between HealthEdge and the customer’s infrastructure.

In addition to the connection point, a Network Address Translation (NAT) IP address is required as an endpoint for routing traffic. The NAT IP address ensures that data is directed correctly between HealthEdge and the customer’s networks, enhancing the efficiency of data transfer.

The dedicated circuit serves as the primary connection between HealthEdge and the customer networks. This dedicated circuit offers superior performance and reliability, ensuring fast and uninterrupted data transfer. However, to further enhance resilience, HealthEdge also establishes an IPsec VPN tunnel as a passive redundant connection. In the event of the dedicated circuit becoming unavailable, the IPsec VPN tunnel acts as a backup, enabling continued data transfer.

Moreover, HealthEdge maintains a secondary IPsec VPN tunnel. This secondary tunnel remains disabled under normal circumstances. However, it can be enabled if the primary data center experiences an outage or during disaster recovery testing. By leveraging this setup, HealthEdge ensures continuous connectivity and data transfer, even in the face of unexpected disruptions.

To learn more about how HealthEdge’s new high-speed connectivity offering, visit www.healthedge.com or email us at [email protected].

 

In a recent webinar titled “Navigating Value-Based Care Through Technology and Automation,” Dr. Sandhya Gardner, MD, Chief Medical Officer at HealthEdge Clinical Solutions, and Mr. Jeff Rivkin, Research Director of Payer IT Strategies at IDC Health Insights, shared valuable insights on the current state of value-based care and the role of technology in its implementation.

The webinar kicked off with Jeff highlighting the advancements payers have made in recent years in value-based care. Payers are transitioning from being merely transactional entities to becoming active partners in care. With the advent of exchanges and marketplaces, payers have focused on improving the shopping experience for enrollment as well as the overall patient satisfaction and engagement. The rise of convenience as a leading factor in healthcare decision-making has led to the emergence of models such as retail health, telehealth, hospital at home, and care anywhere, all aimed at providing accessible and patient-centric care. Additionally, payers have been actively engaging in interoperability, striving to establish an open and seamless system where data can flow between payers, providers, and patients. Artificial intelligence and data analysis have played a crucial role in leveraging payer data to identify care gaps and predict patient needs.

The Role of Technology in Value-Based Care

According to Dr. Gardner, technology plays a pivotal role in facilitating the transition to value-based care by automating manual workflows and leveraging data. Technology can support the efficient delivery of care and improve patient outcomes, while also improving the reach of care management teams by identifying and stratifying at-risk populations. Modern care management solutions offer configurable algorithms to rank member risk based on multiple data sources, including clinical diagnoses, pharmacy claims, and health risk assessments. Digitalizing the intake process and automating care plans can further streamline care management workflows, making them more efficient and increasing member engagement and satisfaction.

Harnessing the Power of Data

Health plans have access to vast amounts of data, ranging from patient experience surveys to medical and pharmacy claims. The challenge lies in sifting through this data to identify relevant and actionable insights. In the webinar, Dr. Gardner emphasized the importance of leveraging data to drive quality improvement rather than merely focusing on compliance. She highlighted the need to surface the right data to the right stakeholders at the right time, enabling health plans to improve performance and outcomes across populations. For instance, data capture can aid in identifying gaps in care and leveraging technology to close those gaps. HealthEdge’s solutions provide configurable assessments and gap closure functionalities, empowering health plans to enhance quality and performance scores while improving patient outcomes.

Adapting to Regulatory Changes

The speakers discussed how technology can assist health plans in adapting to value-based regulatory changes. Examples included incorporating health equity stratification data into assessments to address disparities in care quality across different racial and ethnic groups. Furthermore, modern technology can help health plans meet the requirements of Medicare Advantage and ACA 2023 regulations, particularly in collecting social determinants of health data through health risk assessments (HRAs). Another critical aspect is provider data management and directory requirements, under the No Surprises Act, where HealthEdge’s upcoming provider data management solution can help health plans ensure accurate and up-to-date provider network information.

Accelerating the Journey Toward Value-Based Care Success

This webinar shed light on the progress health plans have made and the opportunities they have in front of them as they pursue their value-based care strategies moving forward. As payers continue to evolve toward become active care partners, embracing convenience and interoperability to enhance patient satisfaction and engagement is critical. Technology solutions have enabled the automation of manual workflows, streamlined care management, and facilitated data-driven decision-making. By harnessing the power of data and leveraging advanced technology, health plans can improve quality, outcomes, and member experiences in the value-based care landscape.

To access the full webinar on-demand, watch the recording here. If you’d like to learn more about how HealthEdge can support payers with value-based care, visit www.healthedge.com.

Creating an Interoperability Strategy that Delivers Results: How to Prioritize Integrations within Care Management and Across the Healthcare Ecosystem

To achieve seamless care coordination, reduce costs, and increase efficiencies, care management platforms must integrate effectively within care management functions as well as across the entire healthcare ecosystem. However, identifying and prioritizing the right integrations can prove challenging for health plans. To get the most out of an interoperability strategy, health plans should understand market drivers and establish goals for what should be accomplished through enhanced integration.

After working with many health plans on developing and executing their interoperability strategies, we have a thorough understanding of how the most successful plans view interoperability.

With the right integrations in place, health plans can break down siloes, support new regulations and payment models, and improve the member experience.

The Race is On: Market Dynamics and Priorities Driving Urgency for Interoperable Care Management Systems

New regulations, evolving payment models, and shifting member expectations are driving urgency for health plans to advance interoperability across multiple systems. For example, the recently proposed CMS rule, “Advancing Interoperability and Improving Prior Authorization Processes,” will prompt health plans to address integration gaps in their prior authorization and utilization management processes. In addition, the transition to value-based care demands more advanced interoperability to allow for better collaboration and outcomes.

Meanwhile, payers are also investing in strategies that improve health outcomes and member experience to advance ratings in the CMS Star Ratings program. Star Ratings can have a significant financial impact for health plans, as moving up from a 3.5- to 4-star rating is worth an additional $400 per member per year on average for Medicare Advantage plans. With member satisfaction and care outcomes being key drivers of the health plan rating, many are finding interoperability to be a critical investment for advancement in these core areas.

Finally, innovation in digital experiences and rising consumerism in the industry continue to shift to member expectations of access to health data and information from across the broader healthcare ecosystem. Members are seeking ease of access to their health and claims data, making efficient exchange of information a top priority.

Integrating the Care Management Function

When building a successful integration strategy to address these needs, health plans should first consider several key integrations within the care management function. These integrations facilitate better care coordination, improve communication, and ultimately optimize health outcomes. To begin, payers should consider how their core care management platform will integrate with solutions housing these types of data:

Social Determinants of Health (SDOH): According to the National Academy of Medicine, new payment models are prompting health plans to prioritize strategies to improve the social wellbeing of their members. SDOH account for approximately 80-90% of a member’s overall health, with medical care accounting for only 10-20%. As a result, many health plans are elevating the importance of investing in ways to enable members to manage aspects of their environment that contribute to overall health.

By systematically integrating care management with SDOH data,  care coordinators can deliver more whole-person care and services by supporting social and economic needs that contribute to a member’s health status. By quickly and easily connecting members with social services, enabling seamless data exchange, and tracking and measuring progress, care coordinators can support overall health needs of their members.

Clinical Criteria: Integrating care management with clinical criteria platforms enables health plans to streamline utilization management (UM) workflows, while informing care strategies that improve outcomes for members and reduce costs for health plans. The integration has become more critical for health plans as costs continue to rise and health plans seek new strategies for improving efficiencies.

Lettering & Correspondence: Timely, clear, and effective communication can advance member engagement, a key factor when it comes to improving overall health outcomes. Integrating care management with lettering and correspondence solutions allows efficient creation of personalized member mailings. Streamlining the process of delivering real-time correspondence for denials, appeals and grievances, and other member communications strengthens member engagement and saves time for health plan administrators.

Business Rules: When business rules are seamlessly integrated with a care management platform, health plans can more effectively manage complex care, automate best practices, and streamline the prior authorization process. Improving efficiencies through this level of integration enables health plans to make strides in preparation for new CMS guidelines to improve processes and efficiencies related to prior authorizations.

Business Intelligence: Health plans are managing more data than ever before. To unlock insights and intelligence behind the data, health plans require use of advanced tools. Integrating reporting and business intelligence allows health plans and care managers to easily access and use the real-time data to improve care management strategy and workflows.

Prioritizing Integrations Across Healthcare Ecosystem

In addition to interoperability within the function, care management solutions should integrate with platforms across the healthcare ecosystem to improve efficiencies and reduce costs. As health plans build their interoperability strategies, health plans should prioritize integrations with other functional systems, including:

Core administrative processing system (CAPS): Integrating claims data into care management workflows allows care managers to incorporate indicators such as repeat provider visits, lack of medication adherence, and missed encounters to create the most effective care plans. With access to the complete view of member history and claims data, care managers can make more informed decisions. Efficient exchange of this type of information is integral to the success of value-based care.

Payment integrity platforms: Interoperability between care management and payment integrity platforms ensures payment teams can access real-time clinical data. As a result, they can improve the accuracy of the claim, configure more effective benefit packages, and reduce provider and member abrasion. The integration also improves efficiencies and reduces costs by eliminating manual data entry.

Digital health management tools: The availability of digital tools and remote monitoring devices for connectivity to patients continues to grow exponentially. With better access to patient data from multiple sources, care managers can more effectively care for members and improve outcomes. According to HIT Consultant, “Creating and utilizing clinical-grade digital health innovations increases adherence and provides members with more accessibility. By utilizing things consumers already have – such as smartphones and videoconferencing platforms – these innovations can create new pathways to care.” Integrating care management platforms with innovative digital health tools not only improves member satisfaction, but also promotes better health outcomes and care quality. By delivering results in these areas, health plans can support value-based care and boost Star Ratings.

Delivering Interoperability Strategy with GuidingCare®

GuidingCare takes a multi-faceted approach to interoperability that includes both integrations within the care management function, as well as those across the entire healthcare ecosystem. With more than 75 unique vendor integrations and 12 productized integrations, and 75 API endpoints to integrate content into native workflows, GuidingCare provides the tools and resources health plans need to successfully execute their care management interoperability strategies.

To learn more about how about how GuidingCare’s highly interoperable platform can accelerate your organization’s care management strategies, visit the GuidingCare page on the HealthEdge website.