Readers Write: A New Industry Standard: How the VBPR IG Is Advancing Value-Based Care

A New Industry Standard: How the VBPR IG Is Advancing Value-Based Care
By Michael Pattwell

Michael Pattwell is principal business advisor for value-based contracting at Edifecs.

The introduction and adoption of the HIPAA transaction standard X12 837 for electronic claim submission revolutionized the way providers were reimbursed in the early 2000s. This standard eliminated administrative overhead for both payers and providers by shifting from paper-based claim submission to electronic submission, reducing claims processing time, errors, and reimbursement turnaround. The standardized structure allowed healthcare providers and payers to communicate efficiently and accurately in a universal format while maintaining security and privacy standards.

Fast forward two decades and the transition from fee-for-service to value-based care has necessitated a new shift. To address this challenge, a new open industry standard has been published to facilitate this transition to value-based care. This standard was designed and developed by the HL7 Da Vinci Project.

The Da Vinci Project is a private sector initiative that addresses the needs of the value-based care community by leveraging the HL7 Fast Healthcare Interoperability Resource (FHIR) platform. The HL7 FHIR platform enables payers, health systems, and other industry participants to identify and enumerate healthcare business use cases that involve managing and sharing clinical and administrative data between industry partners.

On June 17, 2024, The Da Vinci Project published its newest business use case called the “Value-Based Performance Reporting (VBPR) Implementation Guide (IG).” The VBPR IG is designed to support a standards-based exchange of financial and quality performance data based on contractual performance measurements agreed to by payers and providers. The VBPR IG is designed to leverage the existing FHIR resources created for other business use cases. The VBPR IG profiles the “measure report” resource. This existing FHIR resource is profiled by the VBPR IG as is and consumed using the FHIR framework that facilitates this interoperability standard.

This new VBPR IG interoperability standard is designed to solve many of the challenges payers and providers have faced implementing value-based care contracts over the past decade. Some of the challenges that can be solved by implementing the VBPR IG include:

• The timely tracking of performance across contractual measures. It is difficult, if not impossible, for providers to understand how well they are performing prior to various settlement dates.
• Lack of a standard format for value-based care contract performance reporting. There is variation in metrics and methodologies used across payers including financial terms, quality measures, attribution, and reconciliation periods. Reconciling the numerous reports providers receive from multiple payers in unstructured formats. This process is time intensive because reports come from various portals.

The immediate goal of the VBPR IG standard is to enable payers to summarize provider performance across different categories, including lines of business, contracts, populations, quality measures, financial metrics, and reporting periods on a scheduled and ad-hoc basis. Based on the calculated performance scores, incentives are calculated and distributed to providers as rewards or penalties, encouraging continuous improvement in care quality and efficiency.

Solving these critical business problems with value-based care contract transparency and standardization will accelerate the transition away from a fee-for-service reimbursement model to the value-based care model. This will lead to the ultimate goals and objectives to encourage superior care, enhance patient outcomes, and lower costs by compensating providers according to their quality performance, as opposed to the quantity of services provided.

So, what is next for the multi-stakeholder VBPR IG Team at The Da Vinci Project? The next release is is in development. Future releases will continue to extend the VBPR IG and include consuming and leveraging additional FHIR resources. These additional resources include, but are not limited to, CRD IG – Coverage Requirement Discovery and DTR IG – Document Templates and Rules.

Members of HL7’s Da Vinci Project will continue to advance the HL7 FHIR standards and collaborate with all industry stakeholders to accelerate the adoption of a digital future across healthcare. The Da Vinci Project founders and private sector partners are supporting the implementation of the VBPR IG and looking forward to seeing it in action across the industry.