(PART THREE IN A THREE-PART SERIES ON CLINICAL INTEGRATION)
The U.S. Department of Health and Human Services (HHS) has set a goal of tying 30% of traditional, or fee-for-service, Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements by the end of 2016, and tying 50% of payments to these models by the end of 2018, proving that value-based reimbursement is swiftly becoming the norm in today’s healthcare environment.1
However, recent studies show that many of the institutions which were awarded value-based payments this year are now facing government-issued penalties. A recent article in Kaiser Health News reported that 55% of hospitals graded by Medicare on quality––some 1,700––earned higher payments this year for meeting quality metrics. However, fewer than 800 of the 1,700 hospitals that earned bonuses will actually receive extra money because they have been penalized for high hospital readmission rates and hospital acquired infections.2
Payment studies on hospitals, a microcosm of U.S. health care providers, provide useful insight into the pitfalls of value-based purchasing agreements. Moreover, they underscore the importance of understanding what happens to patients outside the hospital in an ambulatory setting. Improving the delivery and value of care requires more than just an electronic health record (EHR) – a robust, integrated healthcare technology infrastructure is critical for a Clinically Integrated Network (CIN) to achieve successful population health management.
Pursuing a population health strategy––the need for robust health technology capabilities
Quality and operational improvements are mandates for functioning CINs. Performance must be measured before it can be improved. The right technology platform is necessary not only to capture the complete picture of clinical and operational performance and form a basis for evaluating physician members, but also to identify patients in need of disease management and intense interventions.4, 5 Without the appropriate technology infrastructure, CINs will have difficulty providing clinical decision-support, reducing variability of care and coordinating care across the network. The right platform is also necessary for the administrative support, scheduling, and practice management needed to maintain a consistent revenue stream for continued network investment.5
Technology interoperability is the challenge
As a result of the recent HHS mandate, most physician groups, independent physician associations (IPA), and hospitals have already invested significant time and financial resources to replace paper-based records with an EHR. However, because not all EHR systems are the same, achieving interoperability across a network is often a challenge. HHS has recently proposed a draft Interoperability Road Map to address the secure exchange and use of electronic health information by both providers and consumers.6 It will, however, be a long time before standards are implemented.
For networks with differing EHR platforms, one solution to the interoperability challenge is to use an EHR-agnostic integrated platform that provides actionable data at the point-of-care. A simple performance dashboard that combines and organizes patient data can be developed to identify clinical gaps in care during a patient encounter and facilitate informed decision-making. Care coordinators are better positioned to intervene and manage a patient population with detailed care plans customized for individual patients and their healthcare needs.
Other dashboards can be developed for practice management reporting purposes. Allowing individual physicians, practice administrators and organizational leadership to track productivity, staffing efficiency, revenue and expenses by physician, site or in total, enables prompt identification of areas of underperformance and the development of concrete improvement strategies to attain performance targets. The ability to combine business intelligence and clinical intelligence is essential to establishing patient registries, improving the quality of care and lowering the overall cost of care.
Disease-based, patient registries are critical to population health management
One of the biggest success factors in transitioning from volume to value is the ability to identify clinically high-risk patients. According to the Medical Expenditure Panel Survey, only 1% of patients were responsible for 20% of health care costs in 2008, and the top 5% of the patient population accounted for nearly 50% of health care costs in 2008 and 2009.7
Proactively managing such clinically high-risk patients is necessary in order to reduce overall costs. A patient or disease registry for specific populations should be established and made accessible to providers across the network. In this way, proactive care and treatment can be delivered to individuals or groups of similar patients, enabling the network to reach quality goals. Patient or population cohort dashboards alert providers of gaps in care or quality measures at the point-of-care. Use of meaningfully-structured EHRs to help track and monitor clinical data across the continuum of services, and an effective ambulatory care strategy, such as the use of centralized care coordinators, can help to identify and engage clinically high-risk patients to keep hospital readmission rates low, for example.
The bottom line
With the appropriate decision-support technology and patient management strategies, a network can thrive in today’s value-based environment. Healthcare technology platforms must go beyond the EHR to improve point-of-care decision-making, improve coordination of patient care, enable implementation of clinical protocols, and track care costs. The ability to document the provision of high quality care at a lower overall cost is key to helping clinically integrated networks negotiate value-based opportunities with payors and employers.
To assist with your strategic planning, download Checklist #3: Does Your Organization Have the Right Tools for Population Health Management?