By Tony Schueth, CEO & Managing Partner

How we pay for health care is undergoing a disruptive, fundamental shift. We rapidly are moving away from the traditional fee-for-service, pay-for-volume approach to one that pays for demonstrated value. In fact, this shift is happening faster than expected. According to one estimate, two-thirds of reimbursements now are based on value and fee-for-service reimbursement should fall below 26% by 2021.

Electronic health records (EHRs) and automated processes are the tools powering this change. Stakeholders are looking to electronic data exchange and analysis to improve patient engagement and quality of care as well as reduce costs.

Many activities are underway to leverage health information technology to achieve the value in value-based care. Here are four predictions for 2019.

1. The industry will double down on real-world solutions to help patients understand the true costs of their therapies. The Real-Time Pharmacy Benefit Check (RTPBC) is a start by exposing many facets of a therapy’s actual costs to the provider and patient. (Click here to learn more about the RTPBC.)
2. EHRs will increase availability of clinical decision support to better merge patient orders against real-world options. This will help the physician make the proper choice for the appropriate patient at the correct time, thus improving speed to therapy and quality of care. It also will tell the clinician what documentation is needed, which will expedite the reimbursement process.
3. There will be an acceleration of efforts to shift the collection of quality-related information needed for value-based care into provider workflows in EHRs. Ensuring that information is captured in workflow will be one way the industry will focus on reducing burden. Another will be continued collaboration to ensure that better measurement is integrated and automated (prospective) for providers and payers powered by collaborations, like Da Vinci, funding Data Exchange for Quality Measures. Moving from large structured documents to discrete data points using Fast Healthcare Interoperability Resources (FHIR) will reduce work and increase trust in provider-sourced content for such issues as data provenance.
4. Payers will unleash patient health records, which will give clinicians a fuller picture of their patients’ health and treatments across providers and sites of care. Health plan records are an untapped silo of valuable information, the availability of which can improve care and outcomes by creating a more complete picture of a patient’s care across all care providers. Work began in earnest in fall 2018 to begin to unleash payer claims and clinical data to care providers via eHealth record exchange.

Looking Ahead. Standards development and multi-stakeholder initiatives are key to advancing ePA, RTPBC, real-time medical benefit check and value-based care. The National Council for Prescription Drug Programs (NCPDP) is actively working to refine and develop standards to advance widespread industry adoption of RTPBC. Meanwhile, Health Level 7, through the Da Vinci Project, is actively rolling out use cases in support of value-based care data exchange. An example is Coverage Requirements Discovery, for which an implementation guide will be published in the fourth quarter of 2019. This use case will enable providers an application program interface (powered by the Fast Healthcare Interoperability Resources—or FHIR—standard) to discover in real time specific payer requirements that may affect the ability to have certain services or devices covered by the responsible payer.

Conclusion. The Point-of-Care Partners team is actively engaged in all of these areas. What we have reported is a drop in the bucket compared to what is planned, what is in progress and what is to come. Want to know more or become involved? Reach out to me at tonys@pocp.com.