Aver’s value-based payment engine works to take the pain out of bundled payment operation for payers, providing an outsourced solution for the management of episodes of care. It is comprised of four major components:
- Episode determination - identify members that are in episodes based on flexible eligibility criteria and establish a budget based on a tiered or variable risk model.
- Concurrent episode monitoring - associate adjudicated claims to episodes and concurrently share episode statuses versus their established budgets with contracted providers.
- Quality data collection - collect quality data based contract rules and incorporate it into episode performance and reconciliation calculations.
- Episode-centric reconciliation - issue settlement payments upon completion of each episode, rather than reconciling completed episodes 6-12 months at a time.
This post focuses on quality data collection, a critical component of meeting the twin goals of any value-based contract—higher quality, lower cost care. In fact, as our CEO, Nick, Augustinos has previously explained, Aver defines a value-based contract as one that considers both quality and cost. Both elements must be present to truly be considered a value-based payment arrangement.
In the context of a bundled payment for an episode of care, patient and quality data are especially important to establishing the episode budget in programs that use a tiered pricing structure. As a reminder, Aver is increasingly seeing use of this risk adjustment and pricing approach that allows for more responsiveness to individual patient risk factors, such as body mass index (BMI), tobacco use, or comorbidity information. This approach can be used to classify patients into one of three risk tiers—low, medium, and high risk—with an episode budget for each tier.
Figure 1. Aver’s Value-Based Payment Engine creates tiered pricing based on risk.
In addition to patient risk factors, the final episode budget for each tier may be adjusted based on quality and outcomes. Aver works with payers to balance many different ways of incorporating quality. Quality measures may be organized along several dimensions, as illustrated below. By balancing across these dimensions the measures payers use in their bundled payment programs, they can reap the benefits of many different factors while minimizing challenges.
"By balancing across these [quality] dimensions the measures payers use in their bundled payment programs, they can reap the benefits of many different factors while minimizing challenges."
For example, as noted below, providers are often better able to control process measures, but these measures don’t convey the “big picture” outcomes on which employers and members are usually focused. By using both types of measures in a bundled payment program, payers can work to satisfy the preferences of all stakeholders.
But, collecting all this quality data across different dimensions is challenging to payers, providers, and sometimes patients. Just as Aver automates the assignment of claims to an episode of care to facilitate measuring care costs, Aver also automates, to the greatest extent possible, the collection of patient risk factors and quality data. The extent of the automation is dependent upon the source of the data.
For example, most Aver clients currently utilize two quality data sources—claims-based data and provider-submitted data. Aver’s value-based payment engine continues to harness claims data as a source of quality information. Examples of claims-based quality data may include measures of readmissions or other potentially avoidable complications.
In bundled payment programs that utilize provider-submitted patient and quality data, Aver makes this process as painless as possible for providers. Certain patient and quality data that is captured in a structured field of the provider’s electronic medical record may be transmitted to Aver via application program interface (API), reducing the data entry burden on the provider. For other data not captured in this way, providers will use the same portal that gives providers (and payers) information about episode budget and concurrent insight into claims applied to the budget as they are processed. Quality data submitted here may include range of motion measures, return to work status, and other standard patient-reported outcomes surveys like HOOS, KOOS, or VR-12. Aver offers payers and providers insight into both quality data and episode budget in the same place, driving bundled program participants to utilize the portal.
Aver pulls this provider-submitted quality data into the value-based payment engine, applies it to the individual episode, and adjusts the total episode budget accordingly. This adjustment also appears on the pricing and quality portal, giving payers and providers concurrent insight into pricing adjustments as the data is processed. The timing of this insight is similar to the concurrent episode monitoring Aver offers in providing near-real time insight into the impact of claims on the episode budget.
Getting quality measurement right is so critical to the success of any bundled payment program, but that doesn’t mean it has to be painful. Aver automates, to the greatest extent possible, the collection of quality data from claims, medical records, and provider submissions and gives payers and providers concurrent insight into the impact of that quality data on the episode budget. This helps providers make mid-course corrections in the care pathway for a patient who needs it and gives payers insight into the quality status of any particular episode of care while it is in process. All of this sets up episode reconciliation payments that may be delivered when the episode is completed, rather than 6-12 months later. I’ll discuss that reconciliation process in a future post.
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