A good flow of data and communication is the lifeblood of a successful relationship between a payer and provider in a value-based contract. Conceptually, this may be a known tenet by health systems and provider groups, but even when data is received, providers may still be challenged by nascent data management practices. Without a complete data picture, insights and analytics are subject to significant limitations. How can providers implement practices to deliver outsized returns in terms of potential value?
From our extensive work in the provider market, our team has put together a list of six core data practices to ensure you are gathering what you need for a complete data picture.
1. Negotiate to receive full eligibility and claims data from payers for all members
To the extent possible, providers should require receiving full claims data and any other applicable reporting data for the populations covered by the value-based contract, for instance lab and pharmacy data. Providers need visibility into the entire patient experience to understand leakage, the pain points of members and providers, and the corresponding improvement opportunities.
2. Develop your own standard data request
If the value-based contract covers a Medicare Advantage population, it requires the format of the Centers for Medicare and Medicaid Services (CMS) “M” files (such as MMR, MA04, or MOR) and the PDE. Be proactive in asking for and understanding what data elements are available from the payer (whether CMS or private insurers) as there may be some that would add value to your management and monitoring of members under the value-based contract. These might include risk scores or modifiers, among others. Having a standardized data request can simplify the data language within your organization and ensure everyone is on the same page.
3. Require monthly claims feeds from payers
Managing members under a value-based contract requires regular review — receiving data quarterly is too infrequent. To the extent possible, it also requires daily ADT feeds from payers (any that they receive from health system partners) to support management of highly acute members at Inpatient facilities or Emergency Departments. Include accountability clauses in your contracts so payers have an incentive to supply accurate and timely data.
4. Reconcile claims data feeds to control totals
When receiving data from a payer, ensure that your ingestion of membership and claims data ties out to the number of records sent as well as aggregate values for membership and claims by month. When sending data to a third-party vendor, require the vendor to show that its intake of that data ties back to the control totals you have provided. It is imperative to have a “source of truth” to serve as home base for the many data analyses needed to understand and serve your population.
5. Request a data dictionary, ensure data fields are accurately filled, and fully understand each field
Often, it is not until the data field is needed that you realize the field is missing or inaccurate, or that what you thought the field represented is something different. In the case of the “M” files, ensure that the payer is not overriding established CMS data columns with home-grown fields.
6. Maintain original data copies
Providers may want to create their own derived variables from data elements in the original files — however, without keeping an original file as provided by the payer, it can be impossible to track down the source of disparities when they arise.
It can seem overwhelming dealing with healthcare data, especially for providers new to value-based care contracting. While the list above is by no means exhaustive, the good news is that whether you are currently doing all, none, or some of these core practices, there is always the opportunity to improve the current process. Greater consistency in the data received across payers and value-based contracts supports providers in managing both their practices and their patients in closing care gaps, managing leakage, prioritizing patient outreach, and improving the odds of value-based contract success.