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Signing a value-based payment contract: The role of data and data sharing
Following a checklist can ensure essential data sharing provisions are included in your value-based contracts with private payers.
Payers generate and house an outsized amount of critical information that your practice needs to effectively manage patient populations. You or your practice leaders should ensure—even insist—that value-based payment contracts clearly articulate the data-sharing responsibilities of each party before entering into these arrangements.
Jump to a section: Essential data | VBP contract review checklist | Tips for working with payers
Essential data held by payers
Payers hold four types of essential data needed for physicians to achieve value-based care success:
- Accurate, comprehensive patient lists to provide clear accountability for value-based payment contracts
- Patient health status (risk level) for proactive identification or patient needs and outreach as needed
- VBP contract-specific performance information to inform quality improvement opportunities
- Cost and quality information to inform high-value referrals
VBP contracts may not always include provisions regarding the sharing of these essential data, but physicians and practice leaders should advocate for their inclusion.
Other data considerations
Depending on the nature of your value-based care model, covered population, and/or practice setting, some data elements will be more important than others. For example:
- Type of VBC arrangement: The data needed may differ depending on the type of model. A pay-for-performance contract will not require the same amount of data as arrangements involving total cost of care accountability. Practices should not enter into any contracts involving downside risk without ensuring payers will provide the needed information.
- Line of business: Traditional Medicare APMs will have set contract terms, leaving no room to negotiate with CMS. The checklist below is meant to be used with private payers, which do offer room for negotiation and may not be as prepared as Traditional Medicare when it comes to information-sharing terms.
- Practice size: For smaller practices that may lack the resources and infrastructure necessary to efficiently handle the data collection and reporting requirements associated with VBC, payers should provide added support (e.g., technical assistance) as needed.
Receiving data from payers
In addition to receiving the right data, contracting entities should ideally ensure that payers:
- Share data in an appropriate manner, using methods and tools that allow the data to be evaluated and implemented into workflows efficiently and in a timely manner
- Create no additional work on behalf of the family physician other than to perform their clinical interpretation and informed decision-making
"When all these pieces are in place, practices can manage populations, they can improve faster in value-based care, and they can confidently take on contracts that reward outcomes, because they will have the data they need to succeed in that model."
Contract checklist for data sharing
Use this checklist, which is organized by essential data element, to ensure that your practice gets the information it needs from a payer. The checklist will help you ensure your contract spells out:
- What data will be shared, including acceptable formats
- When the data will be shared, as well as agreed upon terms for remedying issues when parties do not meet their data sharing obligations
Additionally, although it doesn’t need to be spelled out in a contract, sharing why the information is needed can be helpful for negotiating and conveying to the payer their role in supporting your practice’s success.
Free resource: AAFP Primary Care Information Blueprint
Set the table for conversations about getting the right data to primary care practices.
Accurate, comprehensive patient lists
Why the data are needed: Provides clear accountability for value-based payment contracts. Without it, practices cannot know which patients they are responsible for.
What should be shared:
✔️ Clean eligibility list of attributed members*, including: Member names; Key demographic information; Accurate contact information (e.g., phone, email, preferred contact method); Reason for attribution (e.g., self-attestation, retrospective claims, etc.)
✔️ Format: CSV or excel-based format to allow for easy ingestion
When data should be shared:
✔️ Delivered at the start of the performance year and periodically (preferably monthly) throughout performance period based on model's attribution methodology**
✔️ The contract should specify the day of the month by which this information will be sent
*—Updating or correcting attribution lists is a common challenge; defining this process in the contract is recommended
**—Even if a model’s attribution methodology does not allow for ongoing additions, monthly updates are helpful for monitoring deletions
Patient health status (risk level)
Why the data are needed: Contributes to risk stratification and proactive identification of patients at high or rising risk and prompts outreach for preventive and care management services.
What should be shared:
✔️ Member risk score based on risk adjustment methodology used in the VBP model (e.g., CMS HCCs, ACGs, CDPS, etc.)
✔️ In addition to the risk score, payers may also provide a categorization of risk level (e.g., healthy, at-risk, etc.)*
✔️ Format: CSV or excel-based format (For MA contracts, practices should receive standardized risk reporting data from CMS)
When data should be shared:
✔️ At the start of the performance year and periodically (monthly) throughout performance period
*—More sophisticated payers may even have predictive models that identify members based on anticipated future risk. These are often available through payer portals but receiving in csv format is ideal.
Cost and quality information to inform high-value referrals
Why the data are needed: Supports primary care referral decisions to ensure patients are receiving care from additional high-value (i.e., high quality/low cost) specialists and venues of care.
What should be shared:
✔️ Analysis of claims to identify physicians and care settings shown to efficiently manage discrete clinical episodes (e.g., acute low back pain, GI scope/colonoscopies, etc.); Should also include key quality performance indicators* with information on areas primary care physicians/practices are being measured on and held accountable to (e.g., blood pressure control where cardiologists play a role in co-managing cases of uncontrolled hypertension, avoidable ED use for ambulatory-sensitive conditions where orthopedists, urologists and other specialists can support shared triage protocols to manage symptoms before they escalate)
✔️ Format: Prepared reports; though sophisticated risk-based providers should request raw claims feeds
When data should be shared:
✔️ Ideally, family physicians should receive cost and quality data on potential referral partners in monthly Joint Operating Committee (JOC) meetings (at minimum quarterly)
*—Generally speaking, getting cost data is easier than getting quality data.
VBP contract-specific performance information
Why the data are needed: Allows physicians and practices to monitor performance throughout the performance period to inform improvement opportunities, anticipate needed investments and identify potential deviations worthy of discussing with payer partners prior to the end of the performance period.
What should be shared:
✔️ Financial reporting reconciliations, cost and revenue data on attributed population (e.g., claims paid, incurred-but-not-reported [IBNR]* estimates, etc.)
✔️ Format: Typically comes as a prepared report; request data made available by CMS for MA (e.g., Monthly Membership Records [MMR] data) and/or the state for managed Medicaid populations
✔️ Status on performance relative to key targets on quality; requested at NPI level
✔️ Format: Typically comes as a prepared report; sophisticated practices should request raw claims files to monitor performance on measures derived from claims
✔️ “Chase lists” for care gap closure**
✔️ Format: CSV or excel-based format
*—IBNR may also be referred to as claims runout
**—While payer-delivered chase lists can be inaccurate/dated, getting these provides the practice with the opportunity to update the payer with accurate data so that contract-specific performance under VBP accurately reflects the care being provided.
Free CME: VBC and Technology
Learn how to make data-driven improvements that help you succeed in value-based care.
Tips for working with payers
A few techniques that can help you build a successful strategy for communicating with payers during the contract review process are:
- Establishing shared aims: Aligning with payer partners on the why behind the VBP arrangement can support collaborative negotiations by establishing a common goal/North Star to revisit when negotiations hit a snag. See the AAFP’s Guiding Principles for Value-Based Payment for a set of principles that support family physicians participating in value-based care.
- Including remedies: Contracts should specify remedies for situations when a payer does not meet agreed upon data sharing terms. For example, this can include audit rights or giving physicians the ability to review and contest attribution. The contractual process should define how and when these rights can be exercised. Another option is to include alleviation of normal performance standards when data is not shared in the agreed upon format and timeline.
- Timing of contract negotiation: Payers want to know contracting assumptions before pricing their health plan products for the following year. If payers take this seriously and expect to get real value from provider contracts, contracting discussions should happen in the spring before pricing occurs. Starting these discussions early is important, particularly if practices are asking for more than the payer's standard payment model/approach. It’s recommended to revisit contracts annually to reflect on opportunities to improve information sharing to support shared aims.
- Planning for the future: Payers often have standard reporting packages and may not be willing to deviate. Consider working with the payer—either through contractual terms or otherwise—to plan for more advanced and sophisticated data sharing capabilities in the future through a phased approach or as physicians take on greater levels of risk. Be sure to ask questions about how they plan to update their reporting and analytics based on any new or modified state and federal policies.
- Ensure ongoing communication: Identify key roles and contact persons that will participate in monthly joint operating committee meetings and other recurring touchpoints. Another key contact point should be someone who can help with technical platform optimization.
- Encouraging connection to local HIEs: Encourage payers to connect to local/regional HIE/HDUs in support of a single standards-based approach that facilitates bi-directional, secure, and timely information sharing.
- Understanding data security: Ensure data security measures are in place to protect patient health information. Review the ONC’s Security Risk Assessment (SRA) Tool to understand how to protect patient data.
Learning how to get data right for VBC success? Read how aggregators, conveners, health information exchanges and health data utilities can turn data into actionable information.
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