Synchronizing real-world data to advance alternative payment and care models

Our series on how Privacy Preserving Record Linkage (PPRL) technology can help government agencies synchronize real-world data (RWD) has previously covered topics such as disease surveillance for a rapid response to outbreaks, improving drug safety and gaining a better understanding of health outcomes. With our final blog post in the series, we will delve into alternative payment models (APMs) and care delivery demonstrations.  

The cost of healthcare in the U.S. reached $4.3 trillion in 2021 as advances in medical treatments, while potentially life-saving, are often costly and unproven.1 In response, the Centers for Medicare and Medicaid Services (CMS) has been exploring ways to provide more cost effective yet quality care for our most vulnerable citizens. CMS is achieving this with APMs, which reward healthcare providers for delivering highly-quality and cost-effective care. There are currently APMs for:

  • Specific health conditions, such as for end stage renal disease (ESRD) with the ESRD Treatment Choices Model 
  • Care episodes, such as for joint replacements with the Comprehensive Joint Replacement Model 
  • Provider types, such as primary care providers with the anticipated Making Care Primary model 
  • Particular communities or populations, such as rural areas and the Pennsylvania Rural Health Model 

The hope is that incentivizing quality care will reduce unnecessary hospital stays and emergency visits, which will ultimately reduce costs. APM efforts are also rigorously evaluated for other factors, such as health equity impacts, spillover effects and unintended consequences.

One example of an APM is the Guiding an Improved Dementia Experience (GUIDE) Model focused on Alzheimer’s disease and dementia care. According to CMS, “the GUIDE Model will focus on dementia care management and aims to improve quality of life for people living with dementia, reduce strain on their unpaid caregivers, and enable people living with dementia to remain in their homes and communities. It will achieve these goals through a comprehensive package of care coordination and care management, caregiver education and support, and respite services.”2 

CMS also has efforts to manage new medical treatments that impact drug coverage, and another good example comes from Alzheimer’s disease. With Leqembi®, the first treatment to reduce the buildup of beta-amyloid proteins in the brain to be converted from an accelerated approval to a traditional approval, CMS instituted a coverage with evidence development (CED) program.3 The CED requires prescribing physicians to participate in a registry in order for Medicare patients to receive coverage. The purpose of the registry is to track real-world outcomes and further knowledge of novel treatments. CEDs are being used as an alternative payment model for a number of treatments, including cell and gene therapies. 

The key element with APMs is being able to track outcomes and real-world data from sources such as electronic medical records (EMRs), lab results, pharmacy data, other registries and even commercial payers’ claims can help in a number of ways:

Enhancing insights - CMS and its partners can leverage RWD to gain a deeper understanding of outcomes beyond what can be found in Medicare and Medicaid claims or what physicians report. This can provide insight on appropriate standards of care and how to assess quality to improve both care and payment models.

Beneficiary rolloff - CMS can lose visibility into a patient’s care and ultimate health outcomes when a Medicare or Medicaid beneficiary rolls off of their plan. By synchronizing CMS claims data with those of commercial payers, CMS and its partners can continue to track outcomes to fulfill outcome-based agreements. 

Impacting health equity - Synchronizing non-health or social determinants of health (SDOH) data, related to factors such as transportation, housing, employment, education, etc., can help minimize bias and enable a better understanding of healthcare disparities and how health equity impacts APMs. 

Predicting outcomes - Artificial intelligence and predictive analytics can help predict healthcare trends, costs and clinical responses that can enable the agile reattribution of resources, however, a variety of interoperable, near real-time, HIPAA-compliant RWD sources are needed to do this. 

Model evaluation - Evaluating a model generally requires a comparison group, in this case, a group of non-CMS beneficiaries. RWD can be used to develop a comparison group with granular alignment to CMS beneficiaries, providing a more robust understanding of model impact.

Long-term follow up - Certain treatments, such as cell and gene therapies, require decades of follow up across payers, geographies and providers in order to understand the full impact of care and outcomes. Longitudinal RWD allows for this continual long-term monitoring.

Coordinating care - When there are multiple payers involved, RWD provides access to commercial claims, enabling insight into all patient outcomes.

Accelerating adoption - RWD can also provide insight that can increase provider adoption of APMs and facilitate practice improvement, thus improving quality of care. Additionally, RWD can help strengthen the business case for APM adoption amongst commercial payers, increasing providers’ total share of revenue, as well as quality of care.

Unlocking additional insights

To achieve all of these potential outcomes, an organization needs the ability to source a variety of RWD that is interoperable while maintaining strict privacy and HIPAA compliance. As discussed throughout this series, Privacy-Preserving Record Linkage is an optimal solution to accomplish this. The HealthVerity PPRL solution, also known as Identity Manager, is 10x more accurate than legacy tokenization technologies, FedRAMP authorized and already deployed across numerous government agencies.  

By assigning each individual a universal identifier, known as a HealthVerity ID (HVID), we can synchronize patients over time and across near limitless data sources, creating full interoperability while maintaining patient privacy and HIPAA compliance. This has allowed us to create the nation’s largest healthcare and consumer data ecosystem that government agencies can leverage to seamlessly source and synchronize commercial medical and pharmacy claims, lab results, EMR, hospital chargemaster and SDOH data. 

With our highly accurate PPRL technology and a vast RWD ecosystem, HealthVerity is able to help government agencies gain the insights needed to improve disease surveillance, increase drug safety, better understand health outcomes and advance APMs, ultimately helping to better preserve and promote public health.

Click here to learn how HealthVerity can provide insight to improve APMs or support other data initiatives.

1CMS. National health expenditure data, historical.

2CMS. Guiding an Improved Dementia Experience (GUIDE) Model.

3CMS. Statement: Broader Medicare Coverage of Leqembi Available Following FDA Traditional Approval.

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