by Marie Dieudonne
One of our natural reactions to change is to minimize as much risk as possible. In recent years, we’ve seen big changes in the complexity of Healthcare; to name a few: the passing of the Tax Cuts and Job Act of 2017 and the elimination of ACA individual mandate penalties; policies such as MACRA; initiatives from the US Centers for Medicare and Medicaid Service’s Center for Medicare and Medicaid Innovation (CMMI); uncertain State Medicaid programs; the unrelenting opioid epidemic; and the explosive flu outbreak. In all this change, 2018 trends support successful strategies that remain focused on delivering value in the care provided to patients while minimizing the risks with transitions to Value-Based Care (VBC) models.
Momentum continues for value-based strategies with a more pronounced analytical lens.
Value-based strategies for new delivery models must incorporate the expertise to manage, at a population level, the health of diverse patient sets and the costs associated with care. Those organizations that are not taking the ‘wait and see’ position, but who are learning to work with value-based payment contracts to continue to look for solutions that support their goals while, at the same time, taking financial risks tied to costs and outcomes.
Alternative payment structures will continue to grow, only recently accounting for approximately thirty-percent of all health care payments in the US, as reported from surveys conducted by Health Care Payment Learning & Action Network a public-private partnership launched by the U.S. Department of Health and Human Services (Report dated 10/30/17). As health systems take on more at-risk contracts with payer organizations, they are assuming much of the financial responsibility for the health of their patients, making population health and the acquisition, management, and use of data a critical success factor under value-based care payment models. If the health system is not able to understand the health and wellbeing of the community they serve, they will have difficulty assessing the population to identify patients who might be sicker and require more resources compared to the broader community.
Analytical tools and modeling can predict high-risk patient complications, possible readmission, and the outcomes of a care plans. Predictive models are now incorporating social determinant data, bringing the unique community-level data elements into the analysis, translating to better health outcomes for the patients and improving reimbursements and regulatory compliance.
Value-based contracts require provider organizations to invest in broad care management strategies to reach the “Rising-Risk” populations.
“Rising risk” groups in a population health analysis include people with conditions such as pre-diabetic, hypertension, or kidney disease, i.e. conditions that can be impacted by interventions that support the need for behavior changes in order to reduce health risks and eliminate the “ticking time bomb.”
As VBC becomes better understood, more providers will focus on this population group to manage utilization and costs. The future of Medicaid expansions will put more pressure on the cost of care for “rising -risk” patients in that population segment. Adding complexity, provider organizations will need to work at creating and integrating behavioral health and substance abuse into their care management processes that will drive costs. Organizations will look for assistance for data-driven and efficient processes and services that can be, in part, a value-based payment structure to take on financial risk while managing the limited Medicaid premiums available.
Social Determinants and Behavioral Health programs will become part of every population health strategy and financial arrangement
With the uncontrolled opioid crisis impacting every community as reported every day in the national media, behavioral health and substance abuse co-morbidities will continue to be among the highest healthcare cost drivers. Healthcare delivery organizations will look for relationships to leverage Community Based Organizations (CBOs) and other partners for help with these challenges. Some will start to develop the data models to assess the social need and gaps, learning to include the sometimes vague, extremally variable data elements and devise the standards for assessing the quality of social services. Innovative providers may include CBOs in their risk-based agreements and structures with financial incentive opportunities or innovative strategies that leverage local resources.
As healthcare organizations manage the dynamics of the industry, the one constant is the ever-present need for data and more data.
Analytic solution investments will continue and the ability to derive meaning from the data will be the focus. Organizations will continue to seek assistance to develop the algorithms, analysis tools, and appropriate dashboards for the primary care physicians, specialists, the integrated care managers working the care plan, to the hospital teams, and ultimately for patients with the common goal of offering better care options and enabling improved outcomes. With assistance, healthcare organizations will learn to optimize their agreements towards specific lines of business, leveraging varying facility types, specialty providers, and patient populations. Organizations will work to leverage all data types including health record, claims based, and even self-reported patient-level data to identify gaps, opportunities for innovation, and reward performance based on ability to impact total cost of care and quality of care.
Healthcare organizations will continue to work toward their transformation goal and process improvements needed, moving to incorporate risk and population health analytics and programs while operating in environments struggling to move past volume-based models. This space and it’s regulations and technological advancements are ever-changing – if there’s a particular area you’d like to explore more, learn more about, or just talk about your experiences, feel free to email me! You can find contact information and my professional background here: http://bit.ly/2DPmvk3