By James Furbush
This fall, athenahealth convened live polling discussions with 60 leaders of hospitals, health systems, and independent medical groups at advisory roundtables in California, Massachusetts and Washington, DC.
The goal: to assess the current state of population health management while distilling insights and best practices for the road ahead. Participants ranged from fully capitated west coast organizations to east coast systems just beginning to dip their toes into the waters of risk.
“The opportunity for population health to address healthcare disparities is huge,” said the chief medical quality officer from a Midwest organization. “We’re trying to do more and more, but I still struggle with explaining our population health strategy.”
Here are five of the key insights that emerged.
1. Big data doesn’t equal actionable insights
Forty-three percent of executives selected data aggregation as their highest priority IT investment for population health.
Multiple EHRs, claims data, quality metrics, the overwhelming surge of big data. It’s great to have access to this data, but what do organizations do once they have all that data? How to make sense of the tsunami of zeroes and ones staring back at them from their health IT systems? Data without insight or actionable strategy to move the needle of both quality and cost is nearly useless.
Or, as one executive put it: “Without a single, integrated record of clinical and financial information, regardless of provider or care site we’ll never move the needle on population health.”
But, once organizations have aggregated the necessary information to succeed as the first step on this new reimbursement model journey, the real opportunity to make a difference on health outcomes is to help make sense of that data.
2. Delivering quality care is not the same as financially succeeding under new reimbursement models
Common wisdom suggests that to succeed under value-based reimbursements and new care delivery models, organizations must effectively care for the top five to 10% of their riskiest patients. What isn’t quite known or understood is the most effective game plan for doing so.
As one executive said, there is a delta between the quality measures used to determine successful outcomes, in programs such as PQRS and the like, and true patient quality delivered from providers.
“How can we say ‘use this compass to provide quality care with a straight face?’” wondered one executive. Pay for performance incentives make little sense for certain specialties or emergency department physicians, executives said, and it becomes increasingly difficult to succeed financial and clinically as organizations move toward fully capitated risk. Checking off quality measures like they are boxes on a test will ultimately lead many to game the system for financial advantage.
Until organizations have a better sense of what actually moves the needle on keeping the high-risk patients healthy and therefore total costs down, there will be a lot of experimentation and waste to figure out the successful value-based blueprint.
3. Financial incentives aren’t there yet
Payers routinely come up as one of the most significant roadblocks for provider organizations to make the switch to value-based reimbursement. Of course, each regional market and payer mix differs, but the general sentiment from executives was that payers are “dragging their feet,” as one executive put it. “They don’t want to work with us on these types of new care models,” the executive added.
One of the primary reasons is that when provider organizations move to a fully integrated, total cost of care model, then they can dictate the care delivery method. But, until that happens, provider organizations have to figure out how to care for the patient based on the rules and regulations of each payer.
4. Patient access is an important and key variable
Once organizations are financially responsible for maintaining the health of its patient panels, much of the ability to do so depends on the patients themselves. Are patients adhering to their care plans? Do they have access to care in the right setting when they need it? Are they getting care outside the network? Convenient access – whether through a physical location or via digital communication mechanisms – is such a crucial piece to keeping the costs of caring for patients low.
Some organizations are working to build their own urgent care and retail experiences for patients, or to extend hours, but wherever existing organizations have gaps, there will be “companies that come in and expose our gaps to compete with us.”
Further, by not reacting quickly enough and allowing disruptive entrants to the care delivery system, some executives view patient-friendly competitors as “fractionalizing what we are trying to pull together under our pop health strategies.”
5. When is the tipping point coming?
Though the majority in attendance acknowledged this particular moment in value-based health care is different from the managed care movement in the 90s, many were still skeptical of when the tipping point would come for the industry to fully shift from fee for service to fee for value. “When will the switch and market demand happen,” wondered one executive. “Are we just pushing out this switch every five years?”
For example, with the exception of fully capitated organizations (the Kaisers of the world), nearly all executives polled during these events said their organizations only have upwards of 20% of their reimbursements dependent on value-based contracts. In the next five years, three-fourths of attendees anticipate that number will only increase to around 40% of total revenue. Not exactly the groundswell of change being predicted.
To date, there has been no strong mechanism to move provider organizations off fee for service reimbursement.
It’s clearly still early days in the transition from fee for service to fee for value, but after convening these executives to hear their challenges and opportunities there is a lot of work left to do for provider organizations, payers, vendors and even patients if the industry is going to effectively lower costs and increase quality outcomes.
James Furbush is the Managing Editor of the Health Leadership Forum.
This article was originally published on athenahealth’s Health Leadership Forum.