High Risk vs. Rising Risk Patients: Knowing the Difference Could Save Your ACO Money

Posted by Continuum on Mar 15, 2016 11:00:00 AM

It is well documented that 5% of the population account for 50% of healthcare spend.1 Provider organizations, such as ACOs, often focus expensive complex care management resources on this patient population segment, often referred to as “high-risk” patients. While conventional wisdom supports the approach, a subcategory of “rising risk” patients may represent an even greater opportunity to drive quality and lower the overall cost of care.

Understanding the Difference

Complex care management involves multi-disciplinary, licensed staff who coordinate closely with primary care teams to meet the needs of a practice’s high-risk patients. Selected cohorts may include patients with multiple co-morbidities, selected transitions of care and/or Emergency Department (ED) over-utilization. A complex care management program might also include high-risk patients within certain medication-focused or demographic categories. Such patients are often “high touch,” requiring both face-to-face and telephonic support, and have had numerous acute care episodes and/or high utilization of multiple resources. Keep in mind that while preventing additional acute episodes is important to prevent additional spend, the cost incurred has already occurred and cannot be altered. 

Once identified, care coordinators proactively ensure that these patients receive the right care, at the right place, at the right time using predictive analytics, customized care plans, point-of-care decision-support tools embedded within an EHR, and access to a high quality/high value provider network. While larger provider organizations may be able to support embedded care coordinators, most groups find that a centralized care coordination team serving multiple providers is far more cost-efficient.

Read More

Topics: Coordinated Care, high risk patients, at-risk patients, cost of care, care coordination, ACO

Coordinated Care Best Practices = Successful Outcomes

Posted by Continuum on Apr 27, 2015 2:40:52 PM


The Need for Coordinated Care

The number of Americans with at least one chronic health condition is rising. A Commonweath Fund International Survey found that 23% of patients with a chronic illness saw four or more doctors over the last year and 46% reported taking four or more prescriptions on a regular basis.1 These patients have higher than average healthcare utilization rates, making the management of their care particularly vital, yet complicated. Consequently, a targeted care coordination program is an essential component of any larger Population Health Management initiative.

The successful management of patients with chronic conditions requires care that is well-coordinated between providers, patients, and the care team. The Institute of Medicine has remarked that care coordination “has the potential to improve effectiveness, safety and efficiency of the American health care system”2 and can result in higher survival rates, fewer emergency department visits, and lower medication costs.3 Furthermore, a Health Affairs policy brief found that the lack of coordinated care is costly and created $25 to $45 billion in wasteful spending in 2011 through avoidable complications and unnecessary hospital admissions.4

Read More

Topics: Coordinated Care, population health management, care coordinators

Clinically Integrated Networks: Physicians drive quality healthcare

Posted by Continuum on Feb 13, 2015 9:00:00 AM



Physicians the Driving Force behind CIN Success

With new pressures incurred by the Affordable Care Act and the increasing movement of the US population into Medicare and Medicaid, physicians and hospitals are aligning in different ways in order to take advantage of Shared Savings Programs and other value-based and clinical risk arrangement payment models. 

These associations, called Clinically Integrated Networks (CINs) are groupings of health care providers and facilities that (in theory) work together collaboratively to provide high-quality, cost-effective healthcare to a specific population of patients.1 However, not all CINs are aligned for success or truly clinically integrated. Because physicians are responsible for driving the clinical care of patients, the move to lower overall cost and improved quality accountability needs to start with them.

Quality Care and Clinical Value: Starts with physicians and ends with integration

Historically, physicians trained to work and make decisions autonomously are rewarded for individual achievement. Their value as physicians––as well as their sense of self––was built upon their ability to be the best in their area of specialty.2 This tradition, as well as the Fee-For-Service payment structure, resulted in competition rather than collaboration at its foundation. However, taking advantage of value-based payment opportunities cannot be accomplished working in isolation from integrated systems of care, and requires attention and resources to achieve positive outcomes for entire populations.

 In order to successfully deliver cost-effective quality care, physicians need to work together towards shared clinical goals, regardless of whether they are hospital employees (e.g. Physician Hospital Organization) or tightly managed independent practice associations (IPAs) or group practices. Physicians in an atmosphere of trust and transparency must agree to proven protocols and value-based metrics, and this is often best served by forming a physician-led clinically integrated entity that includes participation criteria. Creating an integration structure helps providers align to take on the higher levels of accountability needed to create a successful CIN. 

The advantage of legal integration

In 1996, the Department of Justice and the Federal Trade Commission set up a definition of clinical integration to allow physicians and health systems to collaborate without fear of antitrust violations.1 In return for setting up a physician-led professionally managed network, specifically defined as having “an active and ongoing program to evaluate and modify practice patterns” while creating a “high degree of interdependence and cooperation…to control costs and ensure quality”, legal entities are allowed to directly contract with large employers, private insurers and other payors for increased reimbursement rates and pay-for-performance rewards.1  However, to meet these requirements, network members, both physicians and hospitals, need to invest in processes and systems for enhanced communications, and services themselves must be coordinated toward a value-based result.1 That means physicians must be engaged and assume leadership roles in healthcare organizations.

Integrated governance and the need for physician leaders

Because many important decisions will require the “buy-in” of different stakeholders, it is important to foster the participation of a representative sample of network members in governance and leadership roles—including employed and independent physicians, primary care physicians, and specialty physicians, hospital executives, and other participating entities, if any. Physicians, used to making independent clinical decisions, may have the temptation to operate at “arm’s length” from the rest of the health system partners, but there is no room for siloed thinking in an integrated network --enter the need for physician leaders. 2

 Physicians who have been in private or group practices may be accustomed to running a small business and managing its resources. However, these skills are very different from those needed to lead delivery system change.  According to physician leaders from three major integrated healthcare delivery systems, the key factor that sets a leader apart from a manager is the ability to create a vision for the future.  Physician leaders must consider how to align all network providers to shape a healthcare delivery system that serves the physical, social, psychological, and financial needs of many patients, rather than individuals. The right leader can inspire physicians to change by helping them gain a clear understanding of why things must change.

Clinical risk arrangment payment models of many types allow IPAs and health systems to invest in leadership development as a strategic priority, and rewarding leadership and skill in group dynamics, as well as rewarding individual competence, may be key to successfully integrating for accountability.1

The bottom line

Medical groups, IPAs and health systems willing to pursue a CIN must empower physician leaders to have an influence on the future direction of the CIN. This will help to integrate the physician's clinical expertise into CIN operations and increase cooperation and credibility among the participants. Furthermore, dedicated physician and administrative leadership will be required to successfully implement a major change project of this magnitude.

Check back next week for Part Two in this series: CIN Participation Qualification and Quality Performance Criteria 




 To assist with your strategic planning, download our FREE Checklist: Is Your Enterprise or Group Ready for Clinical Integration? 

 New Call-to-action


Read More

Topics: Coordinated Care, Value-Based Healthcare, clinical integration, clincially integrated network

Local Care Director - Key to Successful Coordinated Care

Posted by Continuum on Nov 5, 2014 9:45:00 AM

Collaborating with the care team to engage patients

Care coordination is essential to improving utilization management. The Patient Care Team often consists of a nurse Patient Care Coordinator (PCC), a primary care physician and someone within the provider’s office who serves as the PCC’s right hand. This person collaborates with the PCC and helps to engage patients and improve patient care delivery. Introducing the Local Care Director (LCD).

Read More

Topics: Coordinated Care, care continuum, health access, local care director

Reporting Quality Metrics: Easier Said Than Done

Posted by Continuum on Oct 24, 2014 9:49:00 AM

Doctor-with-a-patient_for_PPT_onlyThe Rise of Value-Based Healthcare

The shift from volume-based, fee-for-service healthcare to a value-based model that focuses heavily on quality outcomes has created a host of challenges for providers. While providers have always regarded high quality care as imperative, the ability to demonstrate improved outcomes through quality measure reporting is easier said than done.  

Why is quality measure reporting so critical? In a recent study, payors predicted that traditional fee-for-service reimbursement will change dramatically over the next five years. By 2019, fee-for-service will represent about 30% of all contracts and the balance will consist of various value-based reimbursement programs such as pay for performance, bundled payment and global payments, among others.

Central to all of these value-based contracts is the provider's ability to improve outcomes and report on quality goals set forth by the payor.

Technology Helps, But It's Not the Whole Story

Leaders of well-run medical practices recognize that true patient care has always involved holistic, in-depth knowledge of each patient's history, condition and status. Patient visits, to be truly impactful, must be understood and recorded in a way that enables every member of the medical team to understand patient needs over time.

New technologies, with their dashboards, databases, and ease of use, are tools to support such quality care. But without expert coaching on how to fully maximize their power, providers will be hard pressed to meet quality goals.

Two key aspects worth consideration are the importance of understanding EHR data fields. A complete and accurate set of patient data is crucial to practice performance and quality metric reporting. Secondly, providers should consider a "single sign-on technology," so they are not burdened by logging into multiple applications. 

Read More

Topics: Coordinated Care, EHR Technology, quality metrics

The Benefits of Centralized Coordinated Care

Posted by Continuum on Oct 17, 2014 9:01:00 AM

nurse-care-coordinator-on-phone-with-patientCare Coordination Key Component of Triple Aim Success

Healthcare providers have increasingly implemented programs aimed at coordinating patient care across a fragmented healthcare continuum. Although these programs vary widely in structure and style, the primary goals of care coordination programs—to improve disease outcomes while containing overall healthcare costs—tend to be consistent across organizations.1

Read More

Topics: Coordinated Care, population health management, Triple Aim, care coordinators

Coordinated Care and 7 Other Key Components of Practice Transformation

Posted by Continuum on Sep 26, 2014 1:53:00 PM

The verdict is in: a robust ambulatory care foundation is essential for the future of healthcare. Consequently, primary care practices must transform the way they practice medicine. While this transformation provides opportunities for improved care, a better patient experience and lower costs, it also presents significant and disruptive business and clinical shifts for providers.

Read More

Topics: Practice Transformation, Coordinated Care, Value-Based Healthcare, Patient-Centered Medical Home

Recent Posts

Posts by Topic

see all

Subscribe to Email Updates