The fee-for-service (FFS) payment model that has been the norm in healthcare for decades may finally be on its way out, with many physicians and hospital leaders leaning into value-based care (VBC). However, the path to a VBC future remains challenging, particularly as organizations must face one of the biggest hurdles: data sharing and interoperability.
Smooth and reliable data exchange is crucial for adopting VBC, yet it is fraught with challenges. Healthcare delivery organizations struggle to provide coordinated care with:
- Fragmented data systems with little to no visibility into data from outside organizations
- Inefficient communication tools to connect payers and providers
- Limited patient engagement and high levels of patient frustration as they attempt to navigate the fragmented data landscape
- No centralized, transparent way to share enriched, harmonized data on members and patients
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Data interoperability is crucial for the successful adoption of VBC and other alternative care models, yet it remains a significant challenge in healthcare. The inability to connect and share data within the healthcare ecosystem can result in poor quality care for patients, delayed claim processing, reduced revenue streams for providers, wasted staff time, and higher care costs. When the array of complex datasets exchanged between payers and providers are misaligned, it strains payer-provider relationships.
Payers and providers alike are struggling with data interoperability. It’s clear that a more unified approach to data management is essential for payers to effectively navigate the complexities of value-based care. The following themes highlight the challenge:
1. Payers are struggling to carry out functions essential to VBC – Payers often encounter challenges with executing coordinated care, care management, population health, and health equity programs. These difficulties stem from limited visibility into provider networks, fragmented data systems, and barriers that make provider engagement and collaboration more difficult. We hear from payers struggling with these issues when evaluating care management platforms and looking for solutions to:
- Facilitate effective communication between payers and providers
- Bring together disparate systems and data formats
- Break down information silos
- Engage patients and members in their health journey
- Bridge gaps in whole-person care, particularly by understanding and addressing social determinants of health
- Improve workflow design and execution
These challenges are interconnected, requiring a more coordinated approach to care management than most software platforms can offer.
2. Disconnected point solutions make coordination even harder – Most healthcare organizations have multiple point solutions to address various aspects of care management. These disparate systems often lack the ability to exchange data seamlessly with each other, or with other software in an organization’s tech ecosystem, such as analytics and payment technology. A web of point solutions requires working with multiple vendors, sharing data with multiple external entities (increasing the risk of a data breach or HIPAA violation), and APIs to connect systems and exchange information. All of this can lead to significant delays and errors in data sharing, or manual work to transfer data from one system to another.
3. Payers are concerned about the future of technological alignment – Technological alignment is a common concern for payers due to the complexity and volume of medical data required for operations. Payers are often burdened with maintaining a diverse tech stack to address interoperability and data security issues, streamline utilization management, and support VBC models.
To maximize data, organizations need enterprise data management systems that operate on a single source of truth. They must pull together information from multiple datasets, merging, aggregating, and enriching it into clean, standardized files that can be shared across an organization’s entire tech ecosystem. This removes barriers to payer-provider collaboration and patient engagement. Payers can enhance care management and leverage advanced capabilities like machine learning models for predictive analytics and AI-driven decision support.
Enterprise data management
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All healthcare stakeholders, including payers, providers, and members, deserve access to accurate, enriched data to support informed decision-making throughout the care journey. Advanced enterprise data management systems utilize AI to not only aggregate information from various disparate data sources – such as member and patient records – but also to generate actionable insights that enhance decision-making across care delivery, provider performance, and benefits design.
Through AI-powered consolidation into a centralized data lake, these systems generate meaningful insights on disease risk, care workflows, provider performance, and benefits design, streamlining operations and enhancing strategic decisions. AI-driven processes reduce reliance on manual data extraction or manipulation, significantly minimizing errors and freeing up valuable time from labor-intensive tasks, thus enhancing overall operational efficiency.
A sustainable future for healthcare data
As the healthcare industry transitions from FFS to VBC models, the need for data interoperability continues to rise. Enterprise data management systems designed for our healthcare future offer a comprehensive solution by centralizing and enriching data from disparate sources, enabling more seamless communication and informed decision-making. These systems also empower payers and providers to deliver coordinated, patient-centered care. Embracing enterprise data management – and technologies like AI to harness and make sense of all the available data – will enhance care quality, optimize operations, and ultimately support the successful adoption of VBC models.
Picture: CifoTart, Getty Images
Ashay Thakur is the VP of Data Strategy at Cedar Gate Technologies. He oversees strategic development and governance of the organization's data foundation, driving innovation to enhance scalability, quality, and excellence across Cedar Gate's end-to-end value-based care platform.
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