Today, the US spends more than 17.6 percent of GDP on healthcare. This translates to more than $9,200 per person per year. Although the US spend on healthcare exceeds all other industrialized nations, the US has the lowest life expectancy, highest infant mortality, higher rate of obesity, and more Medicare eligible beneficiaries suffering from two or more chronic diseases. Healthcare is investigating many models to redesign care delivery to exceed the Triple Aim; high quality care, cost-effective, and patient-focused care. This great goal requires significant transformation as the industry moves to quality-based reimbursement from fee-for-service. Through legislation, the federal government repealed the Sustainable Growth Rate when the Medicare Access and CHIP Reauthorization Act of 2015 was signed into law. Additionally, CMS reported this year that 30 percent of fee-for-service reimbursement was tied to quality. CMS expects that by 2018, 90 percent of reimbursement will be tied to quality.
"Participation in the BPCI requires timely data, data analysis, patient-tracking, patient-monitoring, and timely interventions for coordinating staff on behalf of the patient"
Healthcare providers (physicians, hospitals, post-acute facilities) are experiencing dramatic transformation! The rules of the road through MACRA remain in evolution, CMS has initiated shared savings, bundle payments, and because of high cost and poorer outcomes, mandatory bundles. The challenge is to identify patients programmatically, provide high quality, acute and preventive care, exceed a minimum savings rate/target price, account for the transitions of care, and effectively implement patient-centered care plans. How do you do it in every environment of care, during every transition of care, and exceed quality benchmarks?
No simple answer exists! Each healthcare organization is developing their own models to answer their definition of population health and reimbursement reform. What makes the effort so complex?
Health information technology supporting population health has exploded! Both the provider and consumer are inundated by huge variety of applications. The challenge is selecting the right tool-set for the right delivery model, for the right business case, to optimize return on investment, and successfully serve patients while exceeding benchmark expectation.
The healthcare industry is facing operational conundrums operationalizing the Affordable Care Act, MACRA, population health, new models of reimbursement (shared savings, Bundle Payment Care Improvement Program, Medicare Advantage, Medicaid ACO-like shared savings), high-value network design, industry competition, consumer expectation, desire to use new technology to simplify access to care, and local politico-economic factors.
Consider the Bundle Payment Care Improvement Program. CMS identified more than forty episodes of care (each episode may include multiple DRGs). The goal is to minimize variation, focus on quality, and improve the total cost of care. The initiating event begins with the hospital admission and ends after a set period of time (many organizations chose 90 days). The intent of bundles is for the awardee to develop oversight of transitions of care agnostic to the environment (hospital, skilled nursing facility, and home) and to minimize unnecessary interventions, while limiting to cost-of-care less than CMS’ target pricing. For a healthcare organization, the TRANSFORMATION required to collaborate with all healthcare providers representing the continuum of care (pre-acute, acute, and post-acute) requires proficient communication, tracking patients uniquely, and analyzing data on the total population to make strategic operational changes. Participation in the BPCI requires timely data, data analysis, patient-tracking, patient-monitoring, and timely interventions for coordinating staff on behalf of the patient. Just consider all technology vendors and their products designed to support the model as described. Our challenge is to adapt technology strategically, maximize functionality, minimize the toolset, and empower providers to exceed program parameters using clinical decision support, and achieve the Quadruple Aim; Triple Aim plus provider satisfaction.
Using the example of the pneumonia initiating event, readmissions and complications are frequently associated. When a patient is admitted with respiratory distress, the patient must be aggressively treated medically, rehabilitated physically from admission to maintain mobility, minimize the hospital stay, preferentially discharge home, and only if necessary, use a skilled nursing facility. The patient needs to be followed for 90 days (typical bundle duration) from admission. Each transition of care must be scrutinized to align all providers to efficiently treat the patient timely without exceeding expected lengths of stay.
Technology must identify the reimbursement model that the patient is receiving services and document clinical care. From a retrospective perspective, CMS claim data (with the additional barrier to complete patient claim data available nine months after day of admission) must be used to reconcile CMS analysis of awardee’s performance, incorporate prospective data and allow efficient analysis to make actionable system-wide adaptations. The result; provide all care for 90 day less than the target price.
Can a single information platform manage all of these tasks? NO!! Most organizations have employed many technology tools. St. Vincent’s Health Partners, Inc.’s partner organizations have different EMRs, data is shared using Direct, Ensocare to coordinate transfer to SNF, PatientPing to track patients between transitions, and another tool for enterprise care coordinators to manage the translational patient record. With new models, socioeconomic barriers must be anticipated and resolved.
Since patients with pneumonia tend to be readmitted, SVHP is soon to deploy telemedicine between our post-acute members and acute hospital-based physician staff, work with our organized delivery system members to improve telemonitoring utilization, and develop additional support processes (advancing meds to beds) to improve quality and outcomes. This scenario demonstrates no shortage of technology! No shortage for transformation and process improvement. Using current infrastructure, five organizations within an organized delivery system can serve each high-risk bundle patient. The result is COMPLEX workflow, disparate information systems, and too many ways for disruptions in care occur. Healthcare still searches for the “holy grail” of information platforms allowing to minimize the number of technology vendors and software, and improve the patient’s translational health record. For more complexity add the consumer’s drive to use apps. We have only begun to incorporate the consumer and understand what apps they want to use to communicate and share their data with their provider (physician, physical therapist, home nurse, and many more).
So, we stand at the precipice of how to design the model(s) to incorporate technology and successfully exceed the Quadruple Aim meeting new reimbursement models. The healthcare industry is greatly motivated to adapt and transform…we have not seen anything yet!