CAQH CORE is a nonprofit collaboration of over 130 public and private health plans, hospitals and health systems, vendors and other stakeholders across the industry. Through this collaboration, CAQH CORE helps stakeholders uniformly adopt electronic transactions and exchange data efficiently. Since 2005, CAQH CORE has developed and issued four phases of operating rules that support standards, accelerate interoperability and align fee-for-service administrative activities among providers, payers and consumers. In 2015, the CAQH CORE scope expanded to include exchange needs for value-based payment.

Industry Collaboration Required to Avoid Repeating Operational Challenges of Electronic Fee-for-Service Transactions

WASHINGTON, DC - 03/28/2018

New research from CAQH CORE®, released today, analyzes operational challenges that may slow or add costs to the implementation of value-based payment. The research found that industry collaboration is needed to minimize variations and identified five operational opportunity areas that, if improved, would smooth implementation.

“Organizations across the country are experimenting with value-based payment models,” said CAQH CORE Director Erin Weber. “While innovation is needed, it is important that the industry find a common foundation for basic administrative operations.”

The report, “All Together Now: Applying the Lessons of Fee-for-Service to Streamline Adoption of Value-Based Payments” is based on an intensive study by CAQH CORE examining value-based payment operational processes. For each of the five opportunity areas, the report describes the unique challenges associated with value-based payment and makes one or more recommendations. It also suggests organizations that may be best suited to drive the strategies.

The five areas of opportunity include:

  • Data quality and uniformity. Non-standardized data, irregular data and inconsistent use of terminology can cause data to be misinterpreted or not useful. 
  • Interoperability. Non-interoperable systems and processes prevent stakeholders from sharing information and common expectations.
  • Patient risk stratification. Measuring risk is an essential part of value-based care. However, the multitude of risk stratification methodologies erode trust and are a source of confusion.
  • Provider attribution. In value-based payment models, healthcare providers take responsibility for the care of specific patients, yet there is no standard attribution methodology.
  • Quality measurements. Responding to the growing number of clinical quality measurement programs has become an operational burden for providers.

Without collaboration to minimize these variations, the current environment is ripe for repeating a scenario that emerged in the fee-for-service environment more than two decades ago. Much like the operational challenges being encountered today in value-based payment, initial adoption of electronic transactions for fee-for-service payment models was slowed, complicated and made more costly due to a lack of common rules for uniform use. CAQH CORE was created by the industry to address this challenge.

The research released today is a milestone in an ongoing effort launched in 2015 by CAQH CORE to address operational challenges in value-based payment operational models. As the next steps of its commitment, CAQH CORE will share these findings with industry collaborators to encourage action and establish a multi-stakeholder Advisory Group to 1) prioritize report recommendations that will deliver the greatest benefit to health plans, healthcare providers and consumers and 2) determine the appropriate role for CAQH CORE in this endeavor.

CAQH CORE will present an educational webinar on April 10, 2018 at 1:00pm ET featuring Dr. Susan Turney, CEO of Marshfield Clinic Health System and Vice Chair of the CAQH CORE Board, who will introduce the report. Dr. Turney will share her thoughts on how, by collaborating, before proprietary systems and processes become entrenched, the industry can ensure that innovative payment models are unimpeded by administrative burdens.

Register for the complimentary webinar here.

Read the full report here.