CAQH CORE is focusing on value-based payment as part of its industrywide collaboration to help stakeholders uniformly adopt electronic transactions and exchange data efficiently.
We have known for some time that value-based payment (VBP) is coming. Some aspects of VBP are in place today across the industry, while the new Medicare payment structure for alternative payment models (APMs) and Merit-Based Incentive Payment System (MIPS) under MACRA will kick off in 2019. As with any major implementation, many providers and health plans are challenged by the administrative and added costs associated with the transition to VBP. In these early stages, we have an opportunity to streamline administration of VBP across the industry—reducing cost and burden for all.
At CAQH, a not-for-profit alliance that leads the development of shared initiatives to streamline the business of healthcare, the Committee on Operating Rules for Information Exchange (CAQH CORE) is focusing on VBP as part of its industrywide collaboration to help stakeholders uniformly adopt electronic transactions and exchange data efficiently.
See related sidebar: How to Get Involved in CAQH CORE’s Work
In a recent report on VBP, CAQH CORE authors recognized that the VBP environment is ripe to repeat a scenario that occurred more than 20 years ago—a widespread system slowdown as entities took different approaches to fee-for-service data collection and sharing, limiting automation of key administrative business processes. Now CAQH CORE is calling on all healthcare stakeholders to come together to push VBP operations forward and prevent history from repeating itself.
From Fee-for-Service to VBP
When HIPAA was enacted in 1996, it required healthcare practitioners and health plans to exchange administrative data for claims and billing electronically. While standards were required for each transaction, stakeholders implemented and utilized the transaction standards differently. This limited the ability to fully automate information exchange, and the results were costly and burdensome for both providers and health plans. In time, parties came together via CAQH CORE to voluntarily develop common ground rules (e.g., operating rules) for more efficient interactions.
In 2012, the Secretary of the Department of Health and Human Services (HHS) assigned CAQH CORE the task of authoring national operating rules for efficient, large-scale electronic data sharing to support HIPAA transactions. Representing more than 130 organizations, including healthcare providers, health plans, government agencies, associations, vendors, and standards development organizations, CAQH CORE has helped build consistent infrastructure, connectivity, and data content—a set of simplified “rules of the road”—for exchanging healthcare information via standard transactions in the fee-for-service model.
As organizations began implementing various VBP models, CAQH CORE saw immediately that there was no common administrative foundation. Health plans and providers were developing proprietary processes and workarounds to make fee-for-service administrative processes work for VBP. Over a two-year period, CAQH CORE conducted extensive research to understand the challenges encountered by VBP and the once-innovative solutions that have now become roadblocks to progress.
In our research, we found that one of the most challenging aspects of implementing VBP has been the widespread use of proprietary operational systems and processes. For example, some systems use proprietary provider identifiers instead of the required National Provider Identifier (NPI), which makes it hard to match the right provider, patient, service, and time for billing purposes.
CAQH CORE is now launching an effort with the healthcare industry to enable greater uniformity and automation across VBP operations, ensuring that this transition avoids the early pitfalls of fee-for-service. CAQH CORE wants to help the healthcare industry get in front of the challenge now.
CAQH CORE is working to identify areas where common, non-proprietary “rules of the road” can get the healthcare industry on the same page, using same data elements with the same definitions. The intent is that, ultimately, these measures will reduce administrative burdens and streamline VBP operations. All CAQH CORE operating rules and guidelines are vendor- and system-neutral. CAQH CORE seeks to identify opportunities where guidance could be applied across VBP models, regardless of maturity of level or risk.
The CAQH CORE Report
CAQH CORE’s research led to publication of a report called All Together Now: Applying the Lessons of Fee-for-Service to Streamline Adoption of Value-Based Payments . In the report, researchers explained that VBP requires “an efficient, uniform operational system” for stakeholders to achieve “the fluid, reliable, and trusted interactions and exchanges of data” required for VBP to succeed. CAQH CORE identified five opportunity areas to streamline VBP operations.
Data quality and uniformity. Data and terminology must be uniform and consistent to ensure everyone has the data they need and can easily understand it.
Interoperability. Systems and processes must work together to facilitate information sharing with a common set of expectations.
Patient risk stratification. VBP relies in part on measuring risk. Stakeholders must collaborate and promote transparency of models to ensure clarity and build trust.
Provider attribution. For providers to accept responsibility for care of specific patients, improvements in provider awareness of patient attribution methodology and transparency is needed.
Quality measurements. As clinical quality measurement programs proliferate, burdening practitioners, greater consistency is clearly needed.
In a few years, as the industry advances in its transition to VBP, we want to be in a very different paradigm than fee-for-service. This transformation has the potential to change how care is delivered, billed, and paid. We have the opportunity to set the stage for efficient, automated VBP operations, however we can only achieve our aims if we come together now and collaborate on a uniform approach.
For more information on getting involved in CAQH CORE, send an e-mail message to [email protected]. The CAQH team can help stakeholders get engaged in the process, including subgroup participation and webinar attendance.
Erin Richter Weber is director of CORE at CAQH, Washington, D.C.