The conversation in the Value & Reimbursement Roundtable began by looking at value-based care through the lens of accelerators and barriers. Pre-authorizations are perceived as a barrier to care because many physicians find that the process slows downs their clinical workflow, is costly, and burdensome. Participants also thought the term ‘pre-authorization’ was inherently flawed, stating that the name of the process should more accurately reflect its purpose. Pre-authorizations represent an evidence-based review of coverage determination.

The group stated that insurance companies were often a barrier to care and believed the coverage determination process could be automated. Through collaboration with payers and technology companies, roundtable participants envisioned a virtually painless coverage determination process and began planning to implement a digital pilot program that would create a seamless relationship between payers and providers.

This coverage determination system could instantly accept or deny claims and report back to providers the reasons for denial, such as a health plan not offering a procedure or medical device, inconsistencies in a patient’s medical records, or unacceptable test results. The goal is to reduce the burden on the clinical workflow and provide a new type of communication between physicians and patients. With instantaneous insurance coverage information, patients and physicians would be able to craft a better care plan, at the point of care. The group decided three criteria were needed to accelerate the development of a universal value-based care system:

Evidence-based criteria applied in a clinical workflow
A set of “must-haves” that determine the appropriate treatment (procedures, medical devices, services, medications, etc.) for a patient

Harmonization of payer outcome measures
An outcome measure (such as mortality, readmission rates, and patient experience) that is standardized, represents a change in health status of an individual, and recorded after a provider visit

Harmonization for registry submissions
A standardized registry for the various types of value-based care criteria

PILOT: VALUE & REIMBURSEMENT

The digital pilot program took its first step when UnitedHealthcare physicians Dr. Sam Ho, Executive Vice President and Chief Medical Officer, and Dr. Anthony Nguyen, Senior Vice President of Population Health, sent the criteria associated with UnitedHealthcare’s coverage of wheelchairs, sleep apnea studies, and radiology related to lower back pain to Jon Zimmerman, Vice President & General Manager at GE Healthcare.

GE Healthcare will now focus on the creation of technology that can be used to automatically accept or deny claims from payers using evidence-based criteria. From a technological standpoint, Zimmerman believes the process can be created and automated within a few weeks. The key to its success and adoption will be the selection of the appropriate pilot facility. The hospital chosen cannot be too big or small to demonstrate that an automated coverage determination process is feasible in all facilities. Before the pilot occurs, GE will produce a webinar on how to incorporate this new standard into the Electronic Health Record (EHR).

POLICY PLAN: VALUE & REIMBURSEMENT

The Value & Reimbursement Roundtable policy plan calls for eHealth Initiative’s Policy Steering Committee to support the American Hospital Association’s (AHA) letter to increase broadband nationwide, especially in rural areas. AHA supports the increase in data caps and will advocate for this step in the letter. eHealth Initiative also commented on the Trusted Exchange Framework and Common Agreement (TEFCA) and sent a letter on February 20 to make comments on the voluntary data registry.

The most important piece of the value and reimbursement policy plan in 2018 is to educate lawmakers on digital healthcare topics and the issues the private sector is dealing with around value-based care and reimbursements. eHealth Initiative is planning to share the American College of Radiology’s (ACR) Appropriateness Criteria, which uses evidence-based guidelines to assist physicians and other care professionals in making the best imaging and treatment decisions. The plan is to share how technology, the coverage determination pilot, and tools such as the Appropriateness Criteria enhance value-based care.