Uploaded image for project: 'Project Scope Statements/Proposals'
  1. Project Scope Statements/Proposals
  2. PSS-2113

Value Based Performance Reporting Implementation Guide

    XMLWordPrintableJSON

Details

    • Icon: Project Scope Statement Project Scope Statement
    • Resolution: Done
    • Icon: Medium Medium
    • None
    • Hide

      A Value-Based Contract is a written contractual agreement between parties in which the payment for health care goods and services is tied to predetermined, mutually agreed upon terms that are based on clinical circumstances, patient outcomes, financial benchmarks and other specified measures of the appropriateness and effectiveness of the services rendered. With the shift from fee for service to value-based care, Value-Based Contracts have emerged as a mechanism that payers may use to better align their contracting structures with broader changes in the health care system.

      Standardization of payer/provider performance reporting for quality and risk contracts is crucial for health systems and other provider organizations to receive timely interim reports to track and manage their performance on value-based contracts during the term.

      Payer-generated value based performance reports are crucial because payers are generally in the best position to be the arbiters in determining financial performance on risk contracts with health systems. Unfortunately, there is a lack of standardizations for reporting format, the process is usually resource intensive, not very scalable and data reconciliation process is complex. Payers are also facing challenges such as lacking common contract term definitions, for example Total Cost of Care could have many different calculations, retrieving data is time and resource intensive, data is error-prone based on human errors when entering reporting system, and applying rules across different line of business (i.e., PPO, HMO, Federal Employee Benefits).

      Show
      A Value-Based Contract is a written contractual agreement between parties in which the payment for health care goods and services is tied to predetermined, mutually agreed upon terms that are based on clinical circumstances, patient outcomes, financial benchmarks and other specified measures of the appropriateness and effectiveness of the services rendered. With the shift from fee for service to value-based care, Value-Based Contracts have emerged as a mechanism that payers may use to better align their contracting structures with broader changes in the health care system. Standardization of payer/provider performance reporting for quality and risk contracts is crucial for health systems and other provider organizations to receive timely interim reports to track and manage their performance on value-based contracts during the term. Payer-generated value based performance reports are crucial because payers are generally in the best position to be the arbiters in determining financial performance on risk contracts with health systems. Unfortunately, there is a lack of standardizations for reporting format, the process is usually resource intensive, not very scalable and data reconciliation process is complex. Payers are also facing challenges such as lacking common contract term definitions, for example Total Cost of Care could have many different calculations, retrieving data is time and resource intensive, data is error-prone based on human errors when entering reporting system, and applying rules across different line of business (i.e., PPO, HMO, Federal Employee Benefits).
    • Clinical Quality Information
    • Payer/Provider Information Exchange
    • Da Vinci
    • Hide
      Financial Management WG
      Domain experts/business requirement analysts:
      - Vincent Powell (Providence)
      - Michael Pattwell (Edifecs)
      - David Degandi (Cambia)
      - Semira Singh (Providence)
      - Brent Zenobia (Novillus)
      - Heather Kennedy (Humana)
      - Teresa Younkin (POCP)
      - Katie Roan (Optum)
      Show
      Financial Management WG Domain experts/business requirement analysts: - Vincent Powell (Providence) - Michael Pattwell (Edifecs) - David Degandi (Cambia) - Semira Singh (Providence) - Brent Zenobia (Novillus) - Heather Kennedy (Humana) - Teresa Younkin (POCP) - Katie Roan (Optum)
    • Hide
      Humana
      Providence
      Edifecs
      Novillus
      Show
      Humana Providence Edifecs Novillus
    • Hide
      CMS is driving the national movement towards Value-Based Contracting through Medicare programs such as Medicare Shared Savings Program (MSSP), Hospital Value-Based Purchasing (VBP) Program and others. CMS is also driving State Medicaid agencies to submit 1115 waiver requests (Delivery System Reform Incentive Payment (DSRIP)) to radically transform programs with Value-Based Contracting transformations. Provider organization are increasing participation in Medicare Value-Based Contracts.
      Show
      CMS is driving the national movement towards Value-Based Contracting through Medicare programs such as Medicare Shared Savings Program (MSSP), Hospital Value-Based Purchasing (VBP) Program and others. CMS is also driving State Medicaid agencies to submit 1115 waiver requests (Delivery System Reform Incentive Payment (DSRIP)) to radically transform programs with Value-Based Contracting transformations. Provider organization are increasing participation in Medicare Value-Based Contracts.
    • Product Family Product Project Intent Lineage Ballot Type Target Cycle Actions
      		1
      FHIR
      Implementation Guide
      Create New R1 Standard
       
      STU
      September 2023
    • Value Based Performance Reporting, Value Based Performance Report, VBPR, DaVinci VBPR
    • FHIR R4, US-Core
    • N/A
    • Yes
    • No
    • None
    • No
    • N/A
    • Association/Goverment Agency, Healthcare IT Vendors, Healthcare Provider/user, Other, Payer/Third Party Administrator, Providers, Regulatory Agency
    • Accountable Care Organizations (ACOs)
    • US

    Description

      This project aims to develop a FHIR implementation guide to support value-based performance reporting for quality and risk contracts. Standardized bi-directional, FHIR-based communication will connect payer baseline reporting data with provider organization data at the population level. It will also provide the flexibility to compare interim progress at different times during the contract performance period, in addition to notifying providers of non-clinical pre-defined events that may have a direct effect on financial performance and ultimately success. 

      Payers and providers need a standards-based methodology to calculate the quality and financial performance of a provider organization on a value-based contract including but not limited to these parameters:
      •    Contract detail at a population level
      •    Population pool funding
      •    Expenditures (current and target)
      •    Quality and risk (current and target)
      •    Earnings
      •    Performance and incentives

      The project is supported by the Da Vinci Project. The project team will select an initial set of various terms and measures for contract level financial metrics to use as demonstrations and examples of the underlying framework. Wherever applicable, this project will work with existing FHIR artifacts and utilize and reference prior work from, but not limited to, USCore, Da Vinci implementation guides such as Data Exchange for Quality Measure (DEQM), Risk Adjustment, Member Attribution (ATR), Clinical Data Exchange (CDex), Payer Data Exchange (PDex), Health Record Exchange (Hrex), etc.

      This FHIR implementation guide will use the US Core profiles. If this FHIR implementation guide is unable to use a US Core profile, we will follow the Cross Group Projects WG's variance request process, and provide the US Realm Steering Committee an approved rationale for deviation in the implementation guide where applicable.

      Attachments

        1.
        		 Clinical Quality Information PSS Approval Agreed
        2.
        		 PBS Metrics PSS Approval Agreed
        3.
        		 FHIR Management Group PSS Approval Agreed
        4.
        		 US Realm PSS Approval Agreed
        5.
        		 External Terminology PSS Approval Agreed
        6.
        		 Payer/Provider Information Exchange PSS Approval Agreed

        Activity

          People

            Unassigned Unassigned
            yanheras Yan Heras
            Yan Heras Yan Heras
            Yan Heras Yan Heras
            Yan Heras Yan Heras
            Watchers:
            10 Start watching this issue

            Dates

              Created:
              Updated:
              Resolved: