Patient data can be incredibly powerful in determining healthcare costs and related outcomes. But it can also be overwhelming without the proper tools to contextualize what it all means, often resulting in much-maligned “analysis paralysis.” At Clarify Health, our industry-leading data enrichment process combines claims data with trusted clinical informatics methodology to map standard codes and service lines. This approach provides invaluable opportunities for health systems, payers, and healthcare organizations across the United States to identify new opportunities for revenue generation or financial savings. With tailored insights, clinical, operations, and analytics teams can implement programs that support a thoughtful and strategic shift that could result in moving away from a fee-for-service (FFS) model toward value-based care (VBC).

Transitioning from fee-for-service to value-based care model

When it comes to acting on patient data, we know it’s especially tricky for health systems transitioning from a FFS to a VBC model. They typically can’t go 100% in the direction of value without any regard for existing fee-for-service revenue because, at least in the meantime, fee-for-service dollars underpin the majority of payments to most health systems. Health systems must be careful not to cannibalize fee-for-service revenue streams and take a thoughtful approach to map out the shift to a new model over time.

If this sounds like the position you’re in, read on for three no-regrets strategies that we’ve seen work well for our customers shifting to value.

Optimize Skilled Nursing Facility (SNF) referrals

When referring patients to a Skilled Nursing Facility (SNF), you want to be sure they are going to a place with high quality and efficient providers so they can get the best care possible and return home sooner. One way to ensure this happens is to exam the data. Taking raw claims data and enriching it enables Clarify to pinpoint the quality of care and the cost efficiency of facilities within your SNF network. We can look at the data driving a patient’s length of stay, including specifics about each service line. We can do a deep dive into orthopedics patients or specifically look at certain quality measures, such as pressure ulcers. If there’s something that your health system wants to focus on when analyzing your SNF network, we likely can do it.

With our Clarify Markets and Referrals solutions, we can compare SNFs in an apples-to-apples way by accounting for regional variations and adjusting for varying patient complexity on an individual level. Our comprehensive data allows our clients to answer questions, such as:

  • Where are the highest-value post-acute services being offered?
  • Which facilities should I include in my network?
  • Are my providers referring to the highest-performing SNFs for specific diagnoses and service lines?
  • What are the benefits of redirecting referrals to higher-performing SNFs?

Because of our ability to parse the data, we can pinpoint specific ways to intervene. For example, one client had 25 SNF facilities in their network but could focus on just three who were responsible for over 60% of their total SNF spend, allowing for efficient intervention.

Conduct elective procedures in the most appropriate setting

  • Colonoscopies: For low-risk patients, their colonoscopy can be performed at an Ambulatory Surgery Center (ASC) rather than the hospital outpatient department (HOPD). Because the cost is typically much lower in an ASC setting, health systems can benefit from a value-based care perspective, increasing their odds of achieving shared savings. Patients with co-pays and/or co-insurance associated with the procedure will also benefit from the lower cost, thereby driving increased access and patient satisfaction. Additionally, by moving these lower-value procedures to an ASC, the health system frees up the capacity to perform more complex, potentially higher-margin procedures that from a clinical perspective, need to be performed in an HOPD setting.
  • Elective orthopedic procedures: These procedures, such as knee or hip replacements, can also be done at an ASC for low-risk patients. Like shifting colonoscopies, this approach frees up space within the hospital outpatient setting for more complex cases and is in line with moving toward a more value-based care model.

To start formulating a strategy to shift volume, it’s important to narrow-down the data to examine individual providers and where they perform services. For example, we might see that a provider performs 100% of colonoscopies at the hospital. The depth of our data allows us to dig deeper to craft a nuanced approach to taking action. The fact that a provider performs all their procedures in a hospital setting may result from provider preference, or it may be simply that they lack privileges at an ASC, something that could potentially be resolved with an easy administrative fix. This level of specificity to the data allows us to determine exactly what’s driving certain behaviors and craft specific interventions for changing practice patterns.

At Clarify Health, our Transformation and Performance team can partner with your hospital or health system to specifically look at your service line strategies and assess the volume of procedures occurring in both ASC and HOPD settings. Using this data, we can identify the areas of greatest opportunity that are actionable in the short-run and recommend tactics to begin shifting the site of service volumes safely and effectively. We can also get down to a level of granularity that allows you to see the impact of a staged approach (for example: shifting 10% of patients in year one or 20% in year two) that allows you to project your ROI several years in advance. This sort of advisory engagement typically lasts four to eight weeks and includes support in setting up measures of success and metrics to track your interventions on an ongoing basis. 

Improve network optimization

There are a lot of missed opportunities when it comes to referrals and understanding the cost and quality performance of providers within clinically integrated networks. For example, if you’re looking to recruit a physician to join your network, you might hear anecdotes in your community about how they perform but until you get the actual data, you don’t have a sophisticated, quantitative way to assess this provider.

A thorough understanding of physician performance data can help you grow your organization’s network and spur recruiting efforts. For example, you may be considering acquiring a multispecialty practice with many physicians. Even if you have high-level information about how the practice performs, it’s unlikely you have data on individual physician performance. That’s where we can help. Clarify Health provides insights into how individual physicians and individual specialties are performing within a single practice This allows you to easily see any variation and discern which specialties or individuals are driving higher or lower performance.

One example of our work in this area is a client who was considering acquiring a large multispecialty practice in their region. They thought they knew a lot about the practice because the providers were in a value-based care contract and had been generating shared savings for the last few years. But once they realized that the program assessed each practice on their performance against their baseline and didn’t benchmark practices against a regional value, they knew this information was no longer an indicator of efficiency or quality. Using Clarify data however, they were able to do an in-depth analysis of each provider and specialty within the practice and make an informed decision about whether to proceed with the acquisition.

Alternatively, when looking internally at your existing network and considering which data will be most impactful when speaking with physicians about changing their referral patterns, it’s important to note that cost/utilization data typically isn’t convincing on its own. Providers want to know not only that the provider they’re referring to will be cost-efficient, but equally or more important, they want to know that they’ll provide high-quality care.

Clarify provides individual provider-level data regarding performance on a range of specialty-specific quality measures and cost and utilization data adjusted at the individual patient level. This allows you to compare providers easily and fairly across your network and identify your high performers, regardless of how the risk profiles of their populations vary. Additionally, our Transformation and Performance team can be contracted to provide training and insights to your physician liaison teams to further create trust with your providers and drive more productive conversations over time.

Tiffany Wandy is a transformation and performance executive at Clarify Health. She has both payor and provider experience and leverages this extensive knowledge to drive increased use of analytics, business development, and practice transformation for rural, suburban, and urban organizations. For more information on transformation, contact us