Bobby Sherwood is senior director at Burlington, Mass.-based HealthEdge and head of product for GuidingCare. He spoke with Becker's about how payers and providers can build new and better reinforce existing relationships in their steady transition toward value-based care models.
Mr. Sherwood weighed in on how to better enable data-sharing between systems, how to properly utilize it and the high demand for pure EHR integrations. As head of product for GuidingCare, his work focuses on medical management solutions for health plans, including care and utilization management capabilities, skills and grievances, and population health solutions.
Question: What are some of the main challenges in advancing value-based care and its nontraditional payment models?
Bobby Sherwood: From my perspective, I've got a pretty lengthy background in physician to physician to health plan and payer data exchange. That's where I see a lot of the challenges and roadblocks that the market is hitting. A lot of the things that a provider needs to do to be successful in value-based care revolve around using a lot of data effectively, whether it's improving member engagement and focusing on preventive care and wellness, or transferring of the whole patient and care coordination. We're really just tracking their performance. Generally, a single provider or single health system doesn't have all the information that they need to be able to do that. Enabling that data-sharing between all the stakeholders of that patient's care team, and where they receive care, and also from their health plan — which generally is sort of the one central unifying point for that member — is really critical. But it's really hard, because specs and standards are lacking.
There are "standards," but there's a lot of variability in the market, whether it's [Health Level Seven] or [Consolidated Clinical Document Architecture] or [Fast Healthcare Interoperability Resources], etc. And also standards in the sense of understanding what a data element in one system means in another system. That can make it really challenging to bring information together from disparate sources. Obviously, data rights, data security, data privacy is always a challenge and can even sneak into areas where a payer or provider may feel like their data is proprietary, and can and do monetize it. So there's some tension and hesitation there. It also takes a lot of work and it's expensive to move all the data around. Data is getting more and more voluminous and there's more players in the space. It's not just an EHR, it's all the peripherals on the EHR. It's not just a medical management or cap system, it's a lot of peripherals in the health plan ecosystem as well. I think those are some of the big challenges that are prohibiting the data exchange that needs to happen to help drive more success and value-based care.
Q: From the provider perspective, what can payers do to help improve care outcomes for their members under value-based plans?
BS: Being open and transparent is a big piece — open and transparent with their data. I think that goes a long way to sort of reinforce the partnership and trust that has to happen for these contracts and these arrangements to come together and for that successful risk-sharing to take place. Today, we see a lot of just data output sharing — here's your performance scorecard, here are your quality measures, here's a list of your members that we think you should go talk to because they've got gaps in care or need outreach. There are some more advanced providers where they actually just want the raw data to do their own analytics on it, such as powerhouse EHRs and pop-up tools and stuff like that. I think it's a mix of stuff — doing the bare minimum for the less mature providers that are maybe just entering and don't have the advanced tools, but also being much more open and forthcoming with all the data that's available so that providers can plug into whatever tools they want.
Q: From the payer perspective, what can providers do to help improve care outcomes for their members under value-based plans?
BS: We're seeing a lot of demand for pure EHR integrations, at least within GuidingCare. We're still viewing that as sort of the central hub for the provider point of view, but not a lot of data coming out of it in terms of variations. It revolves primarily around the administrative discharge, or to let me know when an acute event happens so that I can put it in my timeline and I can act on it if I want, or I can just feed it to my analytics. Or it's like give me your chart, whether that is just to support an audit, to support information-gathering for an authorization or just to sort of round out the payer chart. I feel like it's not quite as varied as to what payers have been looking to get back compared to what providers are hoping to get.
Q: There isn't always a lot of critical dialogue around value-based care plans. What potential pitfalls and challenges do you foresee and how do we address those when these types of plans are implemented?
BS: I would agree, you always see the upside in the market and all the success stories, and you never hear about where it's not working. Providers need the right information at the right time to be effective, and there's definitely the risk of overwhelming them with information. We talked about all the data they want to get back and run it through tools or get the output stuff. But those datasets are getting bigger and bigger and bigger, as we see the Internet of Things, remote patient monitoring wearables, more and more specialty solutions that create their own data for certain conditions or use cases. If this essential system, whether it's the EHR or the medical management system, can't consume all that and make sense of it for the clinical user, provider, nurse or whomever, it's not going to help, it's not going to be valuable and I don't think you're going to see the outcomes that we want to see out of value-based care.
Q: There are plenty of health systems that are not yet organized in a way that allows for a full value-based approach. Is a partial system possible?
BS: I'm not sure about a partial system other than maybe certain populations. A health system might sort of broach it with bundled payments, with certain conditions and certain procedures. I guess that's starting to move in that direction, and it's not a bad way for people to test the waters for very well defined and finite populations. In terms of sort of getting health systems on board, I think it'll be important for payers to show commitment, and that it's not just a way for payers to remove responsibilities from themselves onto the provider — especially when you get into more and more risk-sharing, a downside risk or even full capitation of outcomes. Again, driving home that partnership, that alignment and that trust level is going to be pretty important there.
Q: A recent National Committee for Quality Assurance discussion talked about how value-based care models aren't necessarily leading to better health equity outcomes among marginalized populations. How do payers and providers work together to make sure they're not falling back into the same unequal care outcomes the pandemic exposed under traditional fee-for-service?
BS: I think that speaks to the growing focus on whole-person care and social determinants — what factors impact a person's health outside of their care setting? Medicaid is actually requiring certain states to use certain SDOH vendors and even certain capabilities of that vendor, like closed-loop reporting. The market leaders and commercial plans are trying to get better in that space. I think that speaks to the fact that we're seeing a pretty big push and focus on customers wanting to do more with social determinants, wanting to partner more meaningfully with some of those key vendors, and having it tie very tightly with our medical management solution from a workflow perspective and especially from a reporting perspective.
Q: How can data collection around value-based care be better improved?
BS: I would say most EHRs or healthcare IT systems have some type of segmentation or risk stratification capability. I think it really comes down to what is the data that's being used? And how thorough is it? And how encompassing is it? There's obviously the clinical data that is native to that system and that is the easiest to use. There's growing adoption of using more publicly available data sources, whether it's just ZIP code information, census information and stuff like that as an additional layer, which directly speaks to some of those SDOH and data points. Then it's the assessment information as well, which is more checkpoint ongoing, where you can trend off of it. So I think a lot of the systems are doing that to some extent, but I think how good they are at it depends on how much data they have and how they use that data. In terms of actually using the output of it, how can we go beyond just the report that we hand off to a provider or a clinical user within our system that says, here's your list to go and make phone calls. How can we have workflows that are more user-friendly and automated?
Q: In terms of when you started your career versus now, what types of differences and trends are you noticing in payer and provider collaboration on value-based care models?
BS: When I started, I hadn't been in healthcare that long. I started at Athenahealth around 2012. That was when CommonWell and Carequality and a lot of the physician-to-physician data exchange and care coordination was the focus in that market. I did a lot of work with the Athenahealth rollout connectivity to those networks for their user base. But that was still pretty early and was just moving giant documents from one system to another. It was just a PDF, and you'd scroll through 80 pages to try to figure it out. There's been a major trend of getting away from that — a not-that-useful data exchange — to try to get more granular and get more precise in the data that's being shared and sharing it in a usable, consumable way for a technology system, whether it's FHIR or specific APIs or something like that. I think that's going to continue to be the case again — to try to find ways to get the signal out of the noise of all that data. I'm seeing a lot more conditions-specific vendors come into play at a lot of our customers for the chronic high-dollar conditions — prediabetes, heart conditions, chronic kidney disease. They want a lot of the data out, but they have very specific targeted data coming back in on very small patient populations and very targeted risk scores. So just more and more specialization in the types of data that we have — that's a risk for a chronic condition or chronic kidney disease and not necessarily just a holistic HCC risk score.