It appears to be an unstoppable force: providers being held more accountable for the care they deliver. Still, we have much to learn about the mature organizational forms, provider capabilities and associated reimbursement models that ultimately will lead to higher-quality, less-expensive and more-accessible care.
For example, while not unexpected, the ability of the Pioneer accountable care organizations to achieve their quality and cost goals has been somewhat mixed. In fact, with nine of the 32 Pioneer ACOs opting out of the program, clearly there is not a one-size-fits-all approach to making ACO implementation work. Similarly, the 114 organizations participating in one of the two larger Medicare ACO efforts also showed uneven results in the first year, according to recently released data from the Centers for Medicare & Medicaid Services. Therefore, we are in for many more years of experimentation and learning about the ACO (and other) models.
The same holds true for population health management, with its heavy emphasis on patient engagement. While the industry has built a solid electronic health record-based foundation to support accountable care and population health, our levels of patient engagement and community integration simply are not as deep as they ought to be. This is compounded by a host of core informatics challenges regarding population health management applications and the realization that the skills required of providers to successfully manage patient populations are still fairly immature.
These skills include improving the sophistication of data management and use practices, successfully driving large-scale organization and culture change, understanding the full gamut of factors that lead to health behavior change, and altering the composition and structure of clinicians to include more team-based care and nonphysician caregivers. While many organizations are well-accomplished in these areas, others have work to do.
As such, while accountability evolves, the next several years will be a Darwinian time for the industry as we determine what works and what doesn't. Perhaps it is also the right time to ask ourselves if we, as an industry, are innovating enough — and how the entire health care ecosystem might collaborate better.
Five Key Areas to Explore
Few problems are more vexing than figuring out how to transform the largest and most complex sector of the economy. Moreover, since we remain in mid-flight, with various public and private sector payment reform efforts still emerging, it is not possible to have a complete understanding of the mature forms of the new health care system.
Collectively, we can let this quasi-chaotic transition paralyze us. Or we can embrace this transformation and seek creative ways to make effective breakthroughs.
In his stellar work Great by Choice, author and researcher Jim Collins and his colleague, Morten T. Hansen, remind us that, even in a chaotic and uncertain world, greatness happens by choice, not by chance. They further point out that leaders who steered their companies through the most difficult times did not have a visionary ability to predict the future. Rather, they observed what worked, figured out why it worked and built on proven foundations. Moreover, they all possessed three core behaviors:
- fanatic discipline — consistency of action and goals no matter what the conditions;
- empirical creativity — a blend of creativity and discipline that relies on direct observation, practical experimentation and tangible evidence to make bold moves from a sound empirical base;
- productive paranoia — staying highly attuned to threats and changes in the environment, even when all is going well; essentially, channeling fear and worry into action.
One could argue that today's health care leaders might aptly apply Collins' framework to guide our efforts as accountability becomes less about theory and more about results.
In the future, we must be careful not to restrict our "solution set" to those of the past. For example, focusing on hospital-physician integration and increasing the adoption and meaningful use of EHRs have certainly been important endeavors, but they won't be enough. Hence, we should consider the following five key areas, which are ripe for further exploration and innovation:
Nontraditional collaborations and business model innovation. In the years ahead, we will see shifts in the roles played by the major participants in the health care ecosystem as well as changes in the relationships between these players.
Retail pharmacies are venturing into medication management in collaboration with providers and are providing front-line primary care. Providers are assuming a risk management function traditionally held by payers. Payers are pursuing a significantly deeper relationship with patients to encourage healthy lifestyles. These changes require collaborations between players that have been antagonists or that largely have ignored each other.
In addition, these players will form relationships based on novel value propositions as a result of the benefits of the diagnostic, therapeutic or care contributions that each brings to the table. These value propositions will be more data-driven, evidence-based and individualized.
For example, providers, payers and pharmaceutical companies may collaborate on medication adherence and management. Providers benefit from medication discounts from a given pharmaceutical supplier and patient engagement expertise from a payer. The pharmaceutical company receives data on medication usage patterns and circumstances. The payer can achieve lower premiums due to improved management of subscribers with a chronic disease.
Most importantly, all members of the value chain will be motivated by the innovative, transparent business model that yields improvements in the patient's health and quality of life.
Use of novel information technology that goes beyond transaction-oriented IT. With the use of EHRs at an all-time high, we now have an opportunity to enhance these transactional-based systems with data and analytics to create effective, knowledge-enabling platforms and fuel the industry's innovation engine.
Think about the combination of data generated from imaging modalities, peripheral health devices such as Fitbits, Web-enabled nutritional calculators and glucose meters, with data generated through social media, census findings, news aggregators and a patient's health record.
These connections will provide valuable information (e.g., on side effects; dosing parameters; environmental, societal and behavioral factors, and so forth) to optimize diagnostic and treatment cycles and to inform new product and service development.
The potential exists to reduce the costs of post-market surveillance and comparative effectiveness studies by an order of magnitude. We know that environmental and behavioral factors, including patient lifestyle, play a significant role in a patient's health, but we don't understand the relationship between these factors. Achieving these potentials is complex, but possibly breathtaking.
The unique convergence of big data, technology innovation, lifestyle choices and economic evolution will spark endless creativity. It will drive the application of data science across disparate, vertical industries, thereby delivering broader concepts and new tools that can be applied to the care process.
Deeper relationships with patients. Providing Americans with greater access to care is a major step forward. But we must ensure that we don't provide access to a system that becomes cold and impersonal in its quest to become more accountable.
As we know, what often matters most during an illness is the human connection between patients and their caregivers. With inpatient utilization declining and care expanding into our communities and homes, each member of the value chain is responsible for protecting and enhancing the sanctity of the patient-provider relationship and improving care coordination.
Furthermore, as the Internet and social media platforms bring patients together with information, each other and a greater voice than ever before, patients now have the power to become potent change agents in how their care is managed. This is not to be taken lightly.
Deepening patient relationships is hard. It is trivial to say, but it is true — each patient is different. Patients have different capabilities, goals and capacities. At times, we think that education is the key to engaging patients, but engagement, as behavioral economics shows us, is much more multifaceted than education. Moreover, our attitude toward engagement often is that patients should just do what we tell them to do. That attitude is not engaging. Finally, we seem to forget that health care is a service, and service excellence goes a long way toward fostering deep relationships with patients.
The true measure of success over the long haul will be whether the nation's providers can demonstrate that, by comprehensively engaging with patients and their families, care is indeed better coordinated, outcomes are improved and costs are decreased.
Viewing government as a collaborator rather than simply a regulator. We've all heard phrases such as "the perfect storm" to describe the overwhelming amount of regulation facing the health care industry. In bracing for this seemingly insurmountable storm, it's easy to bemoan the government and question whether its abundance of policies and regulations will, in fact, deliver the necessary means to the right end. In this case, the end is a reformed and more accountable health care system supported by a robust and interoperable health care IT backbone.
But, despite our tendencies to view government simply as a regulator, we ought to remember that without government involvement, health care in the United States would be a very different enterprise. Notably absent would be the groundbreaking research programs and vast array of medical services benefiting millions of Americans every day.
On a fundamental level, government is and always has been a chief collaborator: funding, guiding, providing access and offering new ways to invigorate the market — essentially establishing and expanding many of health care's core subsectors.
From a purely health care IT perspective, prior to the creation of the Office of the National Coordinator for Health Information Technology and the EHR incentive program, fewer than 4 percent of nonfederal U.S. hospitals had EHR systems with computerized provider order entry. Today, 90 percent of hospitals have CPOE. Previously, less than 20 percent of office-based physicians had any kind of an EHR; today, more than 78 percent do.
These achievements alone are the direct result of collaboration — across government, private sector suppliers and providers of all kinds — and may be our greatest accomplishment as an industry.
More extensive use of a wide range of health professionals. New care delivery models require a transition from individual care providers to collaborative teams engaged in keeping patients well. Some telling professional statistics further support this shift:
- Primary care physician shortages are predicted to reach as high as 40,000 to 52,000 over the next decade.
- Nurse practitioners are the fastest growing segment of the primary care workforce.
- The American Academy of Physician Assistants reports that the number of licensed physician assistants has doubled over the last decade and could increase by another 30 percent by 2020.
As the patient-provider relationship moves from the acutecentric environment to multiple venues of care, the questions become: Will a patient have a better medical outcome (e.g., control his diabetes better) because of these multiple touch points in the care cycle? Will primary care practices that use nonphysician clinicians more extensively have lower costs compared with other primary care practices? Moreover, will the care experience be better or more personal? Will it send patient engagement levels soaring?
Care delivered by a wide range of health professionals has the potential to positively or negatively affect care outcomes and how we perceive the care experience. Only time will tell if we're innovating or collaborating enough to make a positive impact in this area, but it is surely one worthy of our continued focus and learning.
Where Do We Go from Here?
True progress rarely comes in a straight line or on the first try. Ensuring that the accountable health care system of tomorrow delivers on our collective goal of improved quality and decreased cost at the patient and population level, we will need to continue testing new ideas and adapting as we go.
In describing the select companies in Great by Choice who were exceptional overall and especially in chaotic times, Collins noted, "They don't merely react; they create. They don't merely survive; they prevail. They don't merely succeed; they thrive. They build great enterprises that can endure."
Significant change in provider reimbursement represents the most potent form of "disruptive innovation" in health care. It is also an opportunity for deeper collaboration and leadership across the health care ecosystem — a renewed commitment to ensuring that our great enterprise can indeed endure.
John Glaser, Ph.D., is the CEO of the health services business unit of Siemens Healthcare in Malvern, Pa. He is also a regular contributor to H&HN Daily. Neeraj Chopra is the director of strategic consulting, health insight and reform, for Siemens Health Services.