Value-Based Care Solution
for State Medicaid Agencies
Introduction
Medicaid-driven healthcare transformation and payment
reform is no longer a trend – it is a way of doing business
for state Medicaid programs. With growth in the number
of covered lives, sustained pressure to reduce program
costs, and the availability of federal funding for initiatives
ranging from patient centered health homes to multi-payer
State Innovation Models, virtually every state is shifting
away from purchasing volume and leaning towards new
value- based models of delivering and paying for care.
These efforts vary broadly, from bundled payments, to
value-based purchasing requirements in managed care
contracts, regional provider-driven care management
organizations, and in a growing number of states, Delivery
System Reform Incentive Pools and recently proposals.
States are taking a more active role in shaping the
payment terms between managed care companies
and healthcare providers. No longer content to capitate
their Medicaid payments and stand aside as plans pay
providers on a fee- for-service basis, states are increasingly leveraging managed care contracts to ensure that
plans are using value-based payment arrangements with
their network providers, holding providers accountable
and sharing savings (and sometimes losses) with those
providers. A growing number of states now contractually require Medicaid managed care plans to transition a
significant portion of provider payments from fee-for-service to value-based purchasing.
DS Data Sheet | Value-Based Care for State Medicaid Agencies
Providers
Performance Metrics
State Agencies
Data Sharing
Agreements
Labs
MCOs
HIEs
Figure 1: New performance metrics and data sharing requirements
are common to all emerging Medicaid reform models.
Data–more specifically, the capacity to integrate,
aggregate, share and analyze data–is the spark that fuels
reform efforts across all emerging Medicaid delivery
models. The data channel, with integrated information
across clinical, financial and administrative sources, is the
critical stepping stone towards measuring care delivered
to patients and the level of performance to which providers
are adhering. Yet, state Medicaid Agencies, MCOs and
providers have struggled to access to the comprehensive,
integrated claims, financial, demographic and clinical
data necessary to support the shift to value-driven care
reforms. In addition to the data itself, the tools, methods
and workflow needed to analyze these data are typically
multi-year strategic investments in people, training,
technology and new business processes.
1
PAY M E N T S
Connect
Partners
Target
Populations
Design
Contracts
Assemble
Integrated Patient
Records
Coordinate
Care
Monitor for
Compliance
Target
Interventions
Evaluate
Performance
P O P U L State
AT I O N PAY M E N T ” M A N AG E M E N T
Figure 2: Milestones mark progress along the“ Medicaid
Agency’s value-based reform implementations.
Target
Design
Population Analysis,
Program Targeting
Administer
Patient Attribution,
Savings Modeling
Optimize
Payment Calculations,
Program Automation
Program Optimization
H E A LT H
“ P O P U L AT I O N H E A LT H ” M A N A G E M E N T
Monitor
Population
Health
Design
Intervention
Rules
Edifecs Value-Based
Care Solution
Connect
Partners
Manage
Stratification
nnect
H E A LT H
Manage
Patient
Identify
Edifecs offers a comprehensive solution that enables State
Integrated
Data
Data Access
Medicaid
Agencies/ to scalePatient
the implementation of
valueDe-duplication
Services
Repository
Correlation
based care programs at any juncture or milestone in the
Pay for
journey towards pay for value, deliver for quality: Value
Monitor for
“ SDesign
M A R T T R AAssemble
D I N G ” P A Coordinate
R T N E R M A NTarget
AGEMENT
Target
Populations
Member
Journal
PAY M E N T S
ntify
Pay for
Value
TRADING
nage
There is a familiar pattern that State Medicaid Agencies
follow in designing, authorizing, implementing and
overseeing new payment and delivery reform initiatives,
marked by the milestones shown in Figure 2:
Contracts
Mapping /
Validation
Integrated Patient
Records
Care
Interventions
Compliance
Troubleshooting /
Transaction &
Filtering &
“ P O P U L A T I O NEvent
PAY
M E N T ” M A N AIndexing
GEMENT
Correcting
Correlation
Target
Design
Population Analysis,
Program Targeting
Detailed
Dashboard
Administer
Patient Attribution,
Savings Modeling
Clinical Data
Program Optimization
Financial Data
“PO
P U L AT I O N H E A LT H ” M A
NAGEMENT
data
data
Monitor
Population
Health
Provider
Manage
Stratification
Design
Pharmacy
Intervention
Rules
Transaction
Repository
Optimize
Payment Calculations,
Program Automation
Admin. Data
data
Evaluate
Performance
Data
Health
De-duplication /
Correlation
data
PlanIntegrated
Patient
Government
Data Access
Services
Repository
TRADING
“SMART TR ADING” PARTNER MANAGEMENT
Member
Journal
Mapping /
Validation
Troubleshooting /
Correcting
Transaction &
Event Correlation
Filtering &
Indexing
Detailed
Dashboard
Transaction
Repository
Connect
Clinical Data
Admin. Data
data
Patient
data
Provider
Financial Data
data
Pharmacy
data
Health Plan
Government
Figure 3: Edifecs Value-Based Care Solution
DS Data Sheet | Value-Based Care for State Medicaid Agencies
2
Capabilities
Features
Capabilities
Data ingestion and integration
Connects disparate clinical, financial and administrative data sources
Data standards and normalization
Harmonizes data to empower population health decision support, workflow,
analytics and resource optimization
Program set-up and management
Operationalizes pay-for-value programs and new payment reform models,
supporting iteration in design and modeling
Data visualization and dashboard
Creates insights to control costs, identify network leakage and inappropriate
resource use
Integrated workflow
Embeds insights and alerts into clinical and care manager workflow within the
systems used for everyday work
Gain and risk sharing
administration
Supports the full spectrum of gain and risk sharing among MCOs, providers and
other accountable care structures
Reporting, monitoring and audit
Responds to regulatory requirements for data, metric monitoring, milestone
reporting and audit
Correlated data vending
Provides correlated health data to other systems and projects, increasing the
value of all data assets
Program optimization
Iterative program measurement, refinement and review supported by near
real-time information on program performance against KPIs, metrics and
targets
Edifecs Inc. is a global healthcare software company committed to improving outcomes, reducing costs, and elevating value of
healthcare for everyone. Edifecs delivers the industry’s premier IT partnership platform to providers, insurers, pharmacy benefit
management companies, and other trading partners. By mobilizing its leading solutions at the front end of the healthcare information
pipeline, Edifecs provides a unified platform for partners to flexibly pilot and scale new initiatives using their existing enterprise
system. Since 1996, hundreds of healthcare customers have relied on Edifecs partnership solutions to future-proof their leading
initiatives in the midst of a dynamic healthcare landscape. Edifecs is based in Bellevue, WA, with operations internationally. Learn
more about us at edifecs.com.
© 2016 Edifecs Corporation. All Rights Reserved.
www.edifecs.com PN: DS0408.2016.05