Background and Prioritization of Value-based Payments

The CAQH CORE Value-based Payment (VBP) Subgroup launched on April 27, and recently had its third meeting on June 8, 2023. As co-chairs of this important initiative, we’re pleased to share more about the rule development opportunities under consideration, as well as some early insights from our first three meetings.

We are excited to lead this Subgroup. Each of our organizations – respectively representing providers, health plans and vendors – have felt the impact of VBP through complex contracting, data consumption and analysis and the need to prioritize new and innovative care delivery. 

The Underlying Issues Impacting Value-based Payment Operations

Though each of our experiences is unique, we all feel the burden of implementing programs in the context of nascent technical interoperability and non-uniform data exchange. These broad challenges inhibit the streamlined administration of VBP models and lead to the perpetuation – and multiplication – of “stop-gap” workflows.

If value-based payments are to continue their march toward becoming the primary revenue generator in healthcare, more must be done to unify and automate the day-to-day workflows necessary for success. This is where CAQH CORE and its Participating Organizations come in.

Direction and Insights from the CAQH CORE Value-based Payment Subgroup

The VBP Subgroup is positioned to effectively intervene and address operational burden associated with VBP through the development and publication of operating rules defining “rules of the road” for the administration of value-based payment programs. 

The Subgroup is keen to balance foundational improvements that facilitate data uniformity and interoperability while promoting innovative concepts and emerging priorities, such as the collection and incorporation of social determinants of health (SDOH) into program design. We, as co-chairs, are fortunate for the opportunity to guide the Subgroup to this goal while maintaining attention on achievable scopes that advance the impact and applicability of operating rules. 

Each opportunity being pursued by the Subgroup is listed below. The background and genesis of these opportunities are described in more detail in the recently released CAQH CORE Issue Brief, Unifying Value: Industry Opportunities to Streamline Value-based Payment Data Exchange.

1. Standardizing collection of socio-demographic information using the X12 834 Transaction.
2. Strengthening the submission of claims for VBP methodologies using the X12 837 Transaction.
3. Establishing a common VBP infrastructure leveraging CAQH CORE Infrastructure Rules.
4. Aligning industry around semantically interoperable terminology in VBP.

Early Progress and Insights from the CAQH CORE VBP Subgroup

To date, the Subgroup has advanced conversations around the uniform collection of socio-demographic data using the HIPAA-mandated X12 834 Benefit Enrollment and Maintenance Transaction, making early strides in defining data content inclusions and exchange mechanisms. Participants have further considered application of the X12 837 to VBP administration and the role that semantic interoperability plays in streamlining implementations. 

Though Subgroup discussions are varied and far-reaching, a couple points are worthy of elevation in this update:

1. Participants cautioned against overly prescriptive requirements that would stymie innovation in VBP. As such, we are considering solutions that clearly promote best practices, but simultaneously ensure flexibility in implementation – such as aligning industry stakeholders around minimum race and ethnicity reporting requirements, setting a floor but allowing them to determine their ceiling. 
    
2. Subgroup members expressed the importance of a clearly defined purpose for collection and exchange of social determinants of health data to avoid misuse of this highly sensitive information. As a result, the Subgroup is considering how best practice exchange can be accommodated without requiring collection and exchange beyond what is necessary to streamline VBP administration.

As we guide this development process, these insights are critical to ensure that we remain in full consideration of the benefits – and consequences – of this work. 

An Invitation to Participate

The progress and success of this work is contingent upon an engaged group of diverse industry stakeholders. We welcome additions to our roster from CAQH CORE Participating Organizations. If you’d like to learn more about this work or you would like to join the Subgroup, please reach out to Michael Phillips, Sr. Manager, CAQH CORE at mphillips@caqh.org.