How Providence Is Overcoming a Top Value-Based Care Challenge

November 29, 2021 - Providence St. Joseph Health has been at the forefront of delivering high-quality, affordable care to patients. Value-based care is a vital pillar of the health system’s strategic plan for transforming care to improve outcomes and reduce costs. Providence has also identified value-based care models, including capitated primary care for all, as a path forward after the COVID-19 pandemic.

However, there has been one major challenge with transitioning to value-based care models, like the increasingly popular value-based preferred provider organization (PPO) model.

“When we are working with health plans to be accountable for managing the care of patients in a PPO construct, we only have information when the patient touches us. When they are touching other parts in the network of care, we really don’t have any visibility,” Prub Khurana, chief executive and chief strategy officer of Providence St. Joseph Health, recently told RevCycleIntelligence.

Providence is only of the largest health systems in the country with 52 hospitals and over 1,000 clinicians in six states. But the health system still struggles with identifying gaps in care as the 650,000 lives attributed to Providence’s value-based care models move through the entire healthcare continuum, some of which is not owned or affiliated with the health system.

Only about half of the lives in Providence’s value-based care business line touch the health system’s core clinically integrated network and about the same proportion touch community partners contracted by the health system, Khurana reported.

Providers need data on where patients receive care and for what conditions in order to be successful in value-based care arrangements. Providence recently partnered with Anthem Blue Cross and technology vendor Vim to give providers access to the information they need for value-based care.

Leveraging technology to identify gaps in care

Electronic health records (EHRs), health information exchanges (HIEs), and other data-sharing initiatives have tried to facilitate the sharing of patient data across organizations and the care continuum. However, these efforts have not always been successful when it comes to adding value.

For one, community healthcare providers use a variety of EHRs that are not always interoperable with Providence’s Epic suite, Khurana explained. Additionally, HIE technology can facilitate integrations with other EHR systems, but it can cost up to $20,000 to make a connection.

“Providers are very reluctant to sign up and participate when they know it’s going to be either very invasive or just too difficult to integrate with,” Khurana said. “The other point is that there are so many EHRs in our market for our community partners that building integrations with every one of them is just too costly.”

Providence needed a “light touch software platform” that could identify gaps in care and notify the appropriate providers of those gaps when a patient touches the healthcare system. By light touch, Khurana means a technology that shares data in an EHR-agnostic manner so that integration is not a heavy, expensive lift for Providence or community providers in Southern California.

To assist, the health system and Anthem tapped Vim to implement an EHR-integrated application suite to get the right data into the right provider’s hand at the right time.

“The vision here is that a member shows up to a community provider and we’re able to surface to that provider to say that the patient is an Anthem member and a part of this accountable model we’ve built with Anthem. We can tell them this patient needs a screening mammogram, so try to close that gap in care when the patient presents to you,” Khurana explained.

“This way we can ensure that that screening happened and vice versa. If it comes to use and it’s a patient who belongs to a community provider, we can close that gap in care as well.”

Khurana believes a solution for pushing out reminders to providers is “ideal for making a pretty significant dent in what it means to actually manage a population in a value-based care environment.”

“We anticipate using this point-of-care solution for reminders about gaps in care closure for patients [in value-based PPO models] who may not touch our delivery system or who may touch other delivery systems or other community, independent practitioners,” Khurana stated.

“We should be able to close gaps in care for these members who are also Anthem members using that information that is going to come in via the payer.”

Payer collaboration is key

A light touch, EHR-agnostic software platform is key to Providence’s strategy for succeeding in value-based care. But the platform wouldn’t even be possible without help from a payer partner, according to Khurana.

“They really have access to the best information on their members because they’re the ones who usually curate these networks,” Khurana said.

Timely access to claims data and other information, such as who provided care, what was done, and when, is not the norm for providers. There is oftentimes a lag between when providers receive this information from payers, even when both parties agree on a value-based care contract.

“Without having access to information that the payers have, it’s basically impossible to manage care in a longitudinal way across a network like what we’re talking about,” Khurana explained, referencing the value-based PPO models Providence participates in.

Anthem’s role in the new technology partnership is to supply information on gaps in care to create point-of-care reminders for the software platform.

“The idea that we are trying with Anthem and with Vim is to build a virtual, high-performing network of providers that we know have outstanding outcomes. We know they practice medicine the right way and we know that their patient experience is through the roof,” Khurana said. “In collaborating, we’re able to identify this group of physicians and then Anthem is able to furnish the information that we need to close gaps in care through claims data and other data from the platform.”

How to overcome value-based care challenges

Value-based care comes with a unique set of challenges, even when you are one of the largest health systems in the country. Through the years, Providence has learned that those challenges include the need for scale and willing partners.

“You do need a little bit of scale to be able to successfully do value-based care depending on the market,” Khurana explained. “In Southern California, we are so dense. There are 15 million people across LA and Orange County alone. You need to have enough scale in terms of your network to adequately manage a population.”

Many health systems have gotten this scale through mergers and acquisitions, but there are other ways, according to Khurana.

“When I say scale, I don’t mean every delivery system or every physician network needs to have scale in and of itself, but they need a network of partners who are like-minded and who are able to come together and manage care across an entire network. Otherwise, it’s very difficult to give patients enough choice and flexibility if there are not access points out there in the market.”

Willing partners, especially payers, are also crucial to scaling up and being successful.

Jumping into a value-based care model does not guarantee savings or better outcomes. It may take a year or two for providers to realize the benefits of value-based care models, Khurana stated. A payer partner that is also committed to moving to value-based care can make this transition not only easier but possible for providers.

“Having payer partners that are willing to do shared upside for the first couple of years before you get into downside risk is one of the fundamentals here,” Khurana stated.

Overall, this collaboration, whether it is with a payer or a technology vendor or both, is key to the success of value-based care.

“The most important piece of advice I can give is to find like-minded partners because you need partners,” Khurana concluded. “Through collaboration, you’ll be able to better manage the outcomes as opposed to trying to bear the burden on your own. Those like-minded partners will help you on the risk journey and they are absolutely critical.”