Alternative Payment Models: HHS Goes Crowdsourcing

It has been several years since the federal government enacted the Patient Protection and Affordable Care Act (“PPACA”). Since that initial movement to swell the number of healthy individuals covered by some degree of insurance, focus is shifting to efficiency.  New uses of technology are a major aid, arguably the biggest, in the drive to efficient care for millions of Americans.  To aggregate so many alternative payment methods and then discern a plausible way forward, analytics must defy the old adage “less is more” and utilize a more recent phrase: “Big Data.”

For decades, the traditional, fee-for-service pay model rewarded the sheer bulk of procedures that a provider performed.  Under that model, an improper diagnosis that required more visits and time from both doctor and patient would reward a doctor with more pay, whereas a doctor with the correct diagnosis and prescription in a single interaction was paid less even though their analysis was higher quality.

As part of an effort to curb rampant waste in the fee-for-service model (“FFS”) and encourage the best possible health care experiences for everyone involved, the Department of Health and Human Services (“HHS”) set specific goals and launched the Health Care Payment Learning and Action Network (“Network”).  The goals are to tie together 30% of Medicare FFS payments with quality or value through alternative payment models. The Network is the online tool that will advance and spread the progress being made toward value over volume by sharing and consolidating information about the efforts of private, public, and non-profit sectors in one virtual location.

Just how will this coordination across sectors take place?  HHS hired an independent contractor, announced as MITRE, to manage the Network as an outside party and ensure unbiased support.  This support entails the convening of participants to share best practices and thereby reduces unnecessary variation in payment methodologies, as well as facilitates the generation of priorities and summary papers by a guiding committee.  The guiding committee, consisting of Network participants, will address specific topics with more detail and share their findings through webinars or other teleconferences convened by MITRE’s support. Workgroups are to be created by the Network and the guiding committee, with plans to meet and share with more frequency on a variety of topic areas.

Engaging payers, providers, employers, purchasers, states, consumer groups, individual consumers, and other stakeholders is crucial in the transition to the quality over quantity payment model.  That engagement must go farther than only the guiding committee or workgroups. The Network will be accessible for all to discuss, track, and share best practices that promote valuable alternative payment models.  However, engagement on all levels is the crux for the Network.  Without sufficient participation, achieving the critical mass of payers needed to make operational change a viable option is increasingly difficult.  Incentive is a way to motivate business; without a critical mass of payers, the incentive is meager for providers to change payment strategies.  Conversely, a high number of payers concerting efforts will create incentives and speed the transition to alternative payment models.

In order to succeed in the goals set out by HHS, the Network will serve several purposes, all of them to make the move to alternative payment models an easy one.  As the focal point for so many sources of data, the Network connects participants so that they may collaborate with each other.  This unification in the virtual space removes barriers throughout the various levels, sectors and areas of healthcare.  Once connected, participants will work together to share and discover new, or existing, evidence and approaches.  In addition to convening the participants, the Network will also serve to jointly implement the newer models of payment and care delivery across sectors, once they prove to have higher value or quality.  The collection of information into a central source permits the network to pool the data and then identify areas of agreement in the trend to alternative payment models. All this collaboration encourages common approaches to core issues. Using the compiled and analyzed information, the Network’s final proposed function is the generation, dissemination, and implementation of guides for payers, purchasers, providers, and consumers.

Perhaps most importantly is how this information will reach professionals and the public it will affect. The planned process is that the workgroups will share their findings on a specific topic with MITRE, which will then synthesize the content to produce white papers available to the public.  These documents will be available and free of charge to payers, providers, employers, employees, consumer groups and individual consumers, and anyone and everyone with internet access, all through an online database. It is then, when the billions of data points have been processed and manufactured into a precise white paper, that Big Data comes full circle to a concise document that may seem to symbolize “less is more,” but really shows “Big Data is better.”

Andrew Van Lahr is a current student at DePaul University College of Law in Chicago.  Mr. Van Lahr completed his undergraduate degree at the University of Kentucky in English.  He will complete his law degree and certificate in health law in 2017.