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Why should payers and employers care about community care networks?

There’s a growing awareness among employers, community advocates, and the public health sector that issues of diversity, equity, and inclusion (DEI) must be addressed in the healthcare ecosystem if we are to implement genuine value-based care (VBC).

Unlike traditional fee-for-service healthcare, VBC emphasizes keeping people well over “sick care.” As a holistic approach to healthcare, VBC can leverage social determinants of health (SDoH) to develop individualized care plans and to inform population health strategies.

VBC that combines with SDoH to promote health literacy and support DEI values can achieve greater health equity, healthier outcomes, and lower healthcare costs.

But VBC isn’t possible without inclusive value-based benefits design and implementation of value-based benefits administration (VBBA) that incorporates health at the “edge.” That means reaching patients in the home and in the community – physically and through digital technology – to address the needs of vulnerable populations and empower patients through “precision health.”

Per the CDC, precision medicine (also called personalized medicine) enables clinicians to determine a patient’s unique disease risks and develop individualized care plans. Precision health includes precision medicine as well as activities such as disease prevention and health promotion that occur outside a doctor’s office or hospital – that is, “at the edge.” Precision health is empowering because it includes things everyone can do to preserve and improve their health along with actionable public health measures.

Yet precision health is heavily dependent on the ability of providers to share data with community-based organizations (CBOs), such as social service agencies, charities, foundations, and religious groups. CBOs possess SDoH data such as environmental and social factors, which research shows have an 80% impact on a person’s health. Without this data, providers cannot adopt a holistic approach to patients.

That matters not only to patients and providers, but also to payers such as employers and commercial insurance who have a vested interest in reducing healthcare costs through a wellness approach based on prevention, education, inclusiveness, and precision health. By accessing community care networks (CCNs), payer organizations and providers can enable a holistic patient approach that includes SDoH and DEI in its design.

To be effective, CCNs require a number of patient-facing and backend capabilities, including:

    • Integrated data sets combining traditional healthcare data with external SDoH data for prioritized, precision (personalized) interventions via a holistic medical and social record (a longitudinal health record, LHR)
    • Automated referrals, the scaling of efforts via applied machine-learning combined with distributed ledger technology (DLT) “smart contracts”
    • Communication and consent management capabilities to expand access and diversity of recruitment and participation in research, clinical trials, and treatment alternatives
    • Digitization of unstructured data to enhance analytics for risk assessment, prediction and prevention, including patient-provided inputs
    • Automation of the service-invoice-payment continuum to support “convener” models with digitization and automation where community-based providers are reimbursed and/or incentivized

Combining value-based care with CCNs is not easy to do unless you have the right technology with which to combine them. Here are four building blocks, or functionalities, essential to CCNs:

  1. The ability to address SDoH in a focused manner. SDoH data can be leveraged by stratifying a patient population to gain a greater understanding of subgroups and their unique characteristics and challenges. It is imperative, though, that external data is incorporated to provide a holistic view via a LHR.
  2. The ability to triage down to areas of emphasis. Once a population has been stratified, healthcare stakeholders must be able to identify and align programs to address various social determinant buckets. This requires the ability to onboard CBOs, social service agencies, and allied health organizations for behavioral health literacy, health advocacy, and similar initiatives to ensure that patients or health plan members know what’s available to them and how they can obtain assistance or service.
  3. The ability to close the loop on referrals to eliminate care gaps. If a provider has referred a patient to a CBO or social service agency, that provider must be able to confirm that service in fact has been rendered to the patient and that if there is a protocol, it is being followed.
  4. The ability to capture data from the edge. In addition to confirming that the service has been delivered or received, it is important to understand the outcomes. Doing so means being able to capture data from the edge that may be in either structured or unstructured form. This allows stakeholders to see changes in the patient’s health status far sooner than if they rely on a scheduled appointment, a claim submission, or wait until the patient experiences a major health episode. By gathering data from the edge on a routine or even near real-time basis, providers can intervene quickly if there are indications of deterioration in the patient’s condition.

Value-based programs result in better outcomes for patients and lower costs for healthcare providers and payers. CCNs are invaluable contributors to VBC because they have data that provides a holistic view of patients and offers deep insights into SDoH-related factors that impact health outcomes.

Conclusion

The challenge is being able to integrate traditional medical networks with CCNs in a way that aligns all stakeholders (providers, employers/payers, patients, and CBOs) in implementing value-based programs and policies that are fully inclusive and equitable. To fully leverage VBC, employers, payers, and other healthcare stakeholders need the right VBBA platform and tools.

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