Lynn Carroll, Chief Operating Officer of HSBlox, joins Tell Me Where IT Hurts host Jay Anders, MD for a wide-ranging conversation about the new world of value-based contracts, bundled payments, pay-for-performance, reimbursement, payment models, and episodes of care.

But first, Dr. Anders recalls when he was medical director for an HMO, then an insurance company that bought that HMO. He was in charge of utilization management, which meant reviewing doctors’ records to make sure they were meeting utilization standards for medications, labs, and tests. Dr. Anders had a cadre of nurses always looking at such reports, and he’d walk into his office and find a stack of files for review. Some were no-brainers and some were not-so-no-brainers. He contrasts this to today’s era of Medicare Advantage and value-based payments, which he considers a “grand improvement.”

Dr. Anders welcomes Carroll and notes that, as an expert in healthcare insurance and integrated payment ecosystems, and having launched several successful healthcare payment platform businesses when HIPAA was just beginning, he is a bit of a departure from the typical podcast guest.

Carroll started in healthcare working for a provider-sponsored health plan in the 1990s––doing global reimbursement programs, primarily with multi-specialty medical groups and hospital systems looking to for programs to offer to either employers directly or as a result of competition with more traditional commercial insurers. This led to global reimbursement programs, which led to the technology to implement those types of programs and track their performance.  And eventually he landed at HSBlox.

Dr. Anders asks how Carroll sees Medicare Advantage (MA) moving forward and gaining strength. Carroll notes that a technology-fueled shift began in the late 1990s and early 2000s, when HIPAA-standard transactions came into vogue and ushered in more electronic reimbursement programs. Then quality metrics were implemented alongside those reimbursement programs, which led to a melding of outcomes-based programs. Eventually, risk adjusted programs entered the mix, which are significant drivers of the top line in MA plans today.

Dr. Anders wonders about Carroll’s perspective on the role of good data vs. bad data in the pay-for-performance arena. Carroll points out that while data is obviously essential to understanding disease burden at the individual and population levels, and helps to focus resource consumption, it’s important to use data to ensure adequate funding to cover medical expenses. He believes it is a data-driven exercise to understand the population at large, and then drill down to a patient level to understand where to allocate. The question then becomes how to effectively do that.

Regarding interoperability standards, Dr. Anders wonders how Carroll sees them coming into play as the industry tries to manage patients from both a quality and payment acquisition standpoint. Carroll points to the 21st Century Cures Act and the information-blocking component as opening a path to effective data sharing. He notes that the transparency components create an environment where can we wade through the tsunami of data to pull out the pieces that are important, and ultimately get to a more proactive environment with regard to intervention––as opposed to the cost line being based on more retrospective results.

Dr. Anders asks about HSBlox and how it fits in with the 21st Century Cures and the Accountable Care Act. Carroll says that all these programs today have different types of administrative needs beyond traditional scheduling of an appointment, receiving a service, submitting a bill, and having that bill possibly reviewed or ultimately paid. Now there are multi-stakeholder scenarios. For example, in total cost of care program there is a care team to coordinate underneath a fixed price, whether it’s per head, per episode, or per bundle. This means communicating more effectively with open data exchange across the care team in a more proactive or real-time basis. Carroll says that the HSBlox premise is to enable payer-provider collaboration for scaling of these programs.

As far as where fee-for-service is headed, and how it fits in with the new normal as pay-for-performance takes off, Carroll points out that by 2030, we’ll see 100% of dollars being dispersed under some form of pay-for-performance or value-based program. He believes that this is a good, albeit lofty goal, but that some components will continue to lend themselves to fee-for-service.

Dr. Anders asks about the pushback resulting from reported MA overpayments to insurance companies, and how Medicare intends to manage the growth of MA while trying to save U.S. healthcare dollars. Carroll expects continued scrutiny and a hard look at the true cost of disease burden versus how conditions are coded.

As for the role of technology in RAF scores and HCC coding, Dr. Anders asks if it will be scalable enough. Carroll believes it all comes down to applied algorithmic approaches––validating the accuracy of data disparate sources including charts, notes, pharmacy data, administrative data, lab results, etc. Technology has to be applied in an algorithmic manner that it is not only analyzing the data, but validating the disease burden of these populations.

The two take a deeper dive into getting at the true cost of care for a set of diseases with applied algorithmic approaches and timely data sharing.

Dr. Anders asks what Carroll sees in the future for MA value-based programs. As the industry continues down this path, Carroll sees a series of course corrections to understand total cost of care, to ensure the right care teams, and an evaluation of traditional referral paths. Ultimately, the harmonization of benefit design and value-based program design must continue to evolve as these programs are put in place.

Dr. Anders and Carroll then discuss provider evaluation in the context of value-based care and the role of care team coordination, transitions in care, and understanding what services can be effectively provided in the home or community, as well as the ongoing need for patient engagement.

Finally, Dr. Anders finishes with his signature question: “If there’s one thing that you could change in healthcare IT, what would it be?”

“I would like to see patient empowerment in a way that we could motivate individuals to be more proactive with regard to health issues. If we create a scenario where patients have more access to data, better decision-making capability with regard to cost, out-of-pocket components, and don’t have to put off some of the more maintenance-oriented activities that ultimately can result in more acute incidents, then I think we’ve gotten where we need to be.”

Listen to the full podcast here or wherever you get your podcasts.