Demographic Pressure & Regulatory Mandates Driving a Shift to Accountable Care
By Jerry Kolosky
In the United States, value-based reimbursement mandates stipulated by the Affordable Care Act (ACA), Medicare rate cuts implemented by Centers for Medicare and Medicaid Services (CMS), and, in general, the runaway cost of meeting the healthcare needs of the elderly – many of whom suffer from multiple concurrent chronic health conditions – are compelling hospitals, physician practices, and integrated delivery networks to increase operational efficiency, reduce costs, and improve the quality of care.
An emerging, collaborative model of care, known as an Accountable Care Organization (ACO), provides incentives for payors and providers to work together with shared responsibility to deliver system-wide cost savings against defined clinical outcomes, and to promote longitudinal population health and wellness.
A flexible, scalable, connected healthcare ecosystem can facilitate personal commitment to smarter, healthier lifestyles"
While sharing common general objectives, Accountable Care Organizations come in a variety of flavors, including formal pilots implemented by CMS under the Affordable Care Act (such as the Pioneer ACOs and the Medicare Shared Savings Program); shared-risk healthcare organizations supported financial incentives provider by commercial payors; provider organizations that underwrite commercial insurance products; and cross-organizational consortiums in which outcome-based financial risk is borne by the provider network itself.
Tectonic Movement Toward a Technology-Enabled Care Ecosystem
The alignment of financial incentives with care outcomes is an appropriate first step in the direction of new modes of care delivery, but to succeed, Accountable Care Organizations must gradually shift the delivery of appropriate, effective care into the settings of lowest possible acuity across the care continuum, to promote healthy lifestyle choices, and to potentiate a fundamental paradigm shift: from intervention – to prevention.
"The alignment of financial incentives with care outcomes is an appropriate first step in the direction of new modes of care delivery"
This paradigm shift will lead to the continuum-wide, omni-stakeholder utilization of an integrated, technology-enabled connected healthcare ecosystem. A flexible, scalable, connected healthcare ecosystem can facilitate personal commitment to smarter, healthier lifestyles; monitor and improve the health, well being, and productivity of individuals, communities, and cities; enable informed, proactive clinical decision-making; and enable cost-effective chronic care management for older adults and other cohorts with special needs.
It Takes a Network: Transparency, Collaboration, and Interoperability
The emerging connected healthcare ecosystem will provide for the secure capture, management, and delivery of actionable healthcare information directly to the point of need across multiple care settings, and provide tools and condition-specific content in support of patient self-management. User experience optimization is a key to unlocking the potential of these exciting new technologies, and silos of information and "walled garden" models of care delivery will inevitably give way to transparency, collaboration, and system-wide interoperability.
For instance, innovative Telehealth, Remote Patient Monitoring, and mobile health technologies will need to interactive in a meaningful fashion with legacy provider systems – such as Electronic Medical Records (EMR) and Health Information Management (HIM). The attainment of this objective involves the resolution of an interlocking set of non-trivial challenges.
To begin, ubiquitous standards for data aggregation, normalization, analysis, and exchange must be agreed-upon and implemented. A new generation of business policies and procedures, which may require the sharing of data held by competing stakeholders, need to be developed. Complex workflow challenges must be solved, and cross-system compliance with a host of complex regulatory requirements must be met. The resolution of these issues will not be easy. But healthcare information technology challenges of significant magnitude have been faced before – and overcome. From these examples we can draw both insight and inspiration.
The growth of electronic prescribing offers a compelling case study. In 2014, over 67% of the prescriptions written in the United States were transmitted electronically over the Surescripts network. That’s over 6.5 billon electronic prescriptions – more than the number of financial transactions processed by American Express during that same year. The Surescripts electronic prescription network was launched in 2001 to connect physicians with retail pharmacies, but it wasn’t until 2008 when Surescripts was merged with RxHub – a technology platform providing real-time patient identification and prescription drug benefit information to physician practices – did electronic prescribing truly begin to achieve its potential.
Analogously, the emergence of a connected healthcare ecosystem can catalyze the resolution of the challenges surrounding interoperability within a ubiquitous environment of virtual care. Resource-rich organizations can build and support the scalable, device-agnostic technology platform required to facilitate system-wide interoperability, while innovators can rapidly create the edge devices, such as the wearable monitors, mobile communications devices, and analytic algorithms that enable end-user engagement and “care-in-place.”
These are exciting times indeed. With reimbursement policy moving inexorably in the direction of Accountable Care – which requires care coordination across many settings, patient self-management, and outcome-based reimbursement – universally connected, mobile, interoperable health information technology becomes an absolute imperative.