There’s no turning back now. As a nation, we’ve headed far enough down the healthcare reform path that inaction is no longer an option. Forging ahead is the prescribed course of action in all 50 states, where organizations are concurrently vying for limited resources and interpreting multiple legislations, even as they’re working collaboratively with competitors. Honestly, it’s like walking through mud. Deep mud.
Emerging from these seismic changes is the shift toward increased provider risk sharing. But what does this really mean? Fundamentally, it means survival. Provider risk sharing rests on the concept that point-of-care decisions drive utilization and utilization is a major determinant of costs. Providers take on the role of micro-health insurers as they assume risk for the future of costs for their patients. Yet today’s accountable care model goes far beyond the largely-failed capitation approach of the 1990s. And providers soon will experience levels of collaboration they’ve never seen before, with an accompanying need to gather, analyze and exchange information like never before.
But to move ahead, we need to examine the past. Why did capitation fail? Ultimately, because it wasn’t truly patient centered. What will make this time different? What will it take to stay in the game, and even come out a winner? Here’s a snapshot.
Providers will need to know their business at an unprecedented level of detail. For perhaps the first time, they’ll need an accurate accounting of the cost of their services. They’ll benefit from understanding that expanding their marketing share won’t make rain. They’ll want to actualize the potential of this new environment by aligning their incentives with payers and patients. And they’ll recognize that accountable care, with its mix of carrots and sticks, is the new mindset to have.
Enter analytics. Quality driven, collaborative, care-focused organizations are using the precision and interconnectivity of IT to more effectively quantify and manage their risk, both clinical and operational. At the heart of collaborative care is software that stores and interprets clinical information along with costs, as well as networking solutions that ensures smooth, efficient communications among all stakeholders. High on the action item lists of forward-thinking providers are:
- Access to clinical and claims data in near real time, supported by high-speed networks and adequate bandwidth
- Transparency in the form of quality, efficiency and cost profiles
- Evidence-based medicine
- Patient registries (for diabetes, cardiovascular, cancer, preventative health, etc.) also make the list
Meanwhile, data sharing — particularly in the form of Health Information Exchanges (HIE) — is considered indispensable to the success of accountable care. Here’s why: providers are on the front lines of patient care and within the medical community. As such, they play a pivotal role in receiving and delivering care. At the same time, payers (both public and private) can be a valuable source of information for providers. And patients, of course, are at the hub. By connecting dots, aligning interests and sharing risk, all parties stand to win with improved outcomes and reduced costs.
A Peek into the Crystal Ball
Personally, I think the jury is still out on Meaningful Use; we haven’t yet seen whether it can be sustained. But I do believe the industry needs to continue its advance toward a more accountable model of care. With that advance will come the need to improve technical infrastructure.
And as healthcare IT needs become more complex, smart organizations will plan for renewable and expanding costs. Consider system redundancy, for example. Organizations need to know how their data is backed up, what they’ll do if it fails and who will be available 24/7 to provide support. Options like remote hosting offer a redundancy solution, but they must be built into the budget. Beyond redundancy, providers will also need new technologies, relying on them to fully support patient-centered care delivery, with its bundled payments and episodes of care.
Will all hospitals survive the onslaught of change? Probably not. The government has put certain supports in place to help smaller, rural hospitals, but I do believe we’ll continue to see consolidation within the industry.
The bottom line: we’ve been tasked with moving a mountain. It’s a difficult job, and we’re just beginning our climb. But with the right tools and collaborative mindset, our industry as a whole has a clearer shot at success.