Value-based payment (VBP) models pay providers based on the outcomes of the care they deliver, not the volume. VBP models are recognized for their potential to lower costs, increase quality, and promote equity. Almost 60% of healthcare payments are tied to some form of value, be it through pay-for-performance incentives - such as payment add-ons for controlling chronic conditions in a patient population - or shared-risk arrangements between providers and payers, like population-health models that measure performance against a total cost of care benchmark. The penetration of VBP contracts in healthcare is on an upward trajectory and is expected to continue its rise. Despite this acceptance, mixed results of early pilot programs, shifting regulatory priorities, and complexities related to program management threaten to limit adoption of VBP initiatives.

What work has CORE done in this area?

CAQH CORE is an active participant in the VBP space, working closely with industry experts to identify and remove barriers that inhibit meaningful participation in alternative payment models. In 2018, in collaboration with industry experts, CORE released the foundational report All Together Now: Applying the Lessons of Fee-for-Service to Streamline Adoption of Value-Based Payments. In it, five operational opportunity areas were identified that, if addressed, could streamline the adoption and implementation of VBP programs. These areas were: data availability and uniformity, interoperability, risk stratification/adjustment, quality measurement, and patient attribution. The final opportunity area, patient attribution, resulted in the authorship of two CAQH CORE operating rules outlining procedures for payers to provide rosters of all patients attributed to a VBP contract (CAQH CORE Attributed Patient Roster X12 005010X318 834 Data Content Rule) and to indicate patient attribution to a VBP contract during eligibility checks (CAQH CORE Eligibility and Benefits (270/271) Single Patient Attribution Data Rule).

CAQH CORE has validated that the issues identified in these five operational processes have persisted as they were originally outlined in the 2018 report. In some instances, they have evolved due to shifting needs of providers, payers, and the patient population they serve.

What are the emerging issues in Value-based Payments?

The value-based landscape has and continues to change. In evaluating this dynamic environment, CAQH CORE has identified two themes that will shape the future of alternative payment models. The first - the incorporation of social determinants of health (SDOH) into model design - captures the need to address social risks that contribute to harmful health disparities. Second, programs have become more complicated to manage, introducing complex contracting needs and narrower windows of success to providers who are eager to participate in these models. Each of these emerging issue areas and their driving factors will be addressed in greater detail in future CAQH CORE blog posts.

What is CAQH CORE doing now?

CAQH CORE is undertaking an extensive environmental scan, aligning with industry stakeholders to evaluate the need for new or amended operating rules, or formalized industry guidance. If you or your organization would like to learn more or participate in any of our efforts, please contact Michael Phillips, Manager, CAQH CORE (mphillips@caqh.org).