With the ongoing transformation of the health care delivery system, hospitals and health systems must leverage new business models to both deliver and demonstrate value-based care. According to panelists taking part in an executive dialogue on care transformation held May 9 at the AHA’s 2017 Annual Membership Meeting in Washington, D.C., developing clinically integrated delivery networks is an essential strategy for moving from volume to value. However, hospitals’ participation in or management of clinically integrated networks simply lays the foundation for care transformation. Once this structure is in place, various tactics — deployed across the network — shift the organization toward truly delivering value-based care. Here are seven tactics highlighted by the executive dialogue panelists that begin to move the needle.
1. Focus care interventions not on the most at-risk patients but those with emerging risk. While many population health management programs focus on the highest-cost patients to achieve savings, Mike Kotzen, executive vice president, population health at Marlton, N.J.-based Virtua Health System, said Virtua’s interventions had an even stronger impact when deployed to the next tier of at-risk patients. “We had been focused on the population with the top 3 percent of risk, but we’re now starting to see there’s more value in focusing on the 4-to-10 percent,” he said. “Once they’re in that real high-risk category, it’s difficult to make impactful interventions, so we’re trying to focus on that emerging-risk category in an attempt to keep them from becoming high risk.”
2. Invest in the staffing required to support care management of at-risk patients. Adding clinical staff to your organization is often needed to support new workflows and increased patient touchpoints. Forrest General Hospital in Hattiesburg, Miss., participates in an accountable care organization led by Hattiesburg Clinic. The Clinic has hired over 30 case manager RNs, one MSW, and one Diabetes Educator to supplement the primary care teams and to scale up their efforts to help close quality gaps, improve chronic disease management and improve care transitions. The hospital itself has hired two Palliative Care physicians to specifically coordinate care for admitted ACO patients and to assist with appropriate end of life care, said Forrest General President and CEO Evan Dillard. “The clinic has been successful, in part, because they have access to dozens of case managers that determine how patients are doing, and where they’re going after the acute hospital admission, whether it’s to home with an outpatient appointment or to a post-acute facility,” he said.
3. Partner with other organizations to positively impact social determinants of health. Health care providers have long partnered with community organizations to improve community health. Now, as hospitals focus on population health, these ties are strengthening. “In the state of Washington, health care and community organizations in each of the counties are partnering on social determinants of health,” said Lois Bernstein, chief community executive for Tacoma, Wash.-based MultiCare Health System. “If you don’t have food, how can you be healthy? If you don’t have transportation, you can’t get to your appointments.”
However, community organizations aren’t the only organizations that can help drive healthy behaviors in a population. St. Louis-based Ascension Health recently partnered with Lyft to help patients find transportation to appointments, said Jason Dinger, COO of Ascension Care Management.
4. Recognize that different populations may need different interventions. Resist the urge to roll out any intervention to all patients with a certain condition. Instead, test the impact of the intervention in various patient populations. “We’re finding that populations are segmenting differently in terms of the support they need from us,” said Dinger of Ascension Care Management.
“The Medicare Advantage population is a lot different than a commercial [insurance] population, and both are different than the Medicaid population. If you’re working with a commercial population, you need tools for price transparency and other kinds of convenience factors,” he explained. “The Medicaid population needs more support for social determinants of health, like transportation. The challenge is how do we honor the needs of the distinct populations while aggregating those in a way that we can scale.”
5. Examine your ability to scale. Panelists agreed that scale is almost a prerequisite for more sophisticated value-based care models, since scale is needed to make investments in the IT systems, predictive analytics and dashboards needed to guide care management. Interestingly, the panelists noted scale can be achieved without dominating any single regional market.
“I understand the quest for scale, but it seems more about total revenue or covered lives now than it is about dominating any market,” said Dave Edwards, senior vice president of corporate accounts, Siemens Healthineers. “So while you have scale, you may not dominate an individual market, meaning you can’t just go in and demand certain rates from payers, like we traditionally think of when we talk about scale.”
Greg Walker, CEO, Wentworth-Douglass Hospital in Dover, N.H., agreed dominating your local market is no longer the only way to scale; depending on the size of the market, it may not even be adequate. “You need to have enough covered lives at the clinical level. You don’t have to necessarily obtain that from one market.”
Ascension embodies this new approach to scale, and Dinger explained the rationale: “A large employer is going to have employees in multiple geographies, and any narrow network it offers to employees will have to service 70 to 80 percent of those employees. You have to build that,” he explained.
6. When in doubt, focus on improving quality. Alvin Hoover, CEO of King’s Daughters Medical Center in Brookhaven, Miss., reminded the group that success in value-based models is predicated on providing high-quality care. Providers that fail to focus on continually improving clinical quality will find no care management model or intervention can overcome quality shortfalls. “We’ve learned that efficiency is important, but so is effectiveness,” he said. “We started paying attention to the quality and hoping that improving our quality would reduce our cost. We’ve found that to be true.”
7. Rethink how success is measured. As the adage goes, “what gets measured gets managed.” A focus on quality improvement may lead organizations toward a shorter length of stay, but the panelists agreed that a shorter stay isn’t the best goal — no stay is.
“We are now measuring healthy days,” said Dinger of Ascension Care Management.
Measures like healthy days prioritize patients and their preferences, as most patients never want to see the inside of a hospital.
“People want to say in their homes,” said Bernstein of MultiCare. “They want to be more self-sufficient and independent, and technology is already beginning to play a role in [helping manage patients outside of the hospital].”
Tom Kearney, vice president, business development, for Siemens, agreed technology that enables condition management at home will continue to play a role in lowering the overall cost of care. “Technology enables care at the right place, at the right time and in the right location,” he said, noting that in the future, the "right" place may increasingly be outside a health care facility.
While keeping patients' health managed at home is the ultimate goal for nearly every health care provider, Doug Shaw, COO of AHA Health Forum and moderator of the executive dialogue, worried that current reimbursement models may slow providers’ ability to do just that. “How do we adjust for the current revenue models that support hospitals? Current models are, in part, based on hospitals being used.”
While much uncertainty remains, particularly on the reimbursement side, health care organizations are transforming their delivery models to optimize performance and deliver value-based care.