Our annual healthcare spending growth rate was the lowest in 53 years in 2013, but more is needed to reduce the growing percentage of GDP spent on healthcare while strides continue to be made to improve quality. Groups already participating in ACO programs have shown their commitment to contain or reduce costs while improving quality. ACO participants as well as our government are recognizing the need to change the existing incentive model, which by definition falls short of producing the best scenarios to both reduce costs and improve quality. Because of government and market pressures, fee for service is starting to lose the legs it stands on and capitation, although looked upon unfavorably by many provider organizations, can be an important tool for managing costs as part of transitioning to the fee for value model. Many organizations struggle in the same areas when trying to manage their patient populations effectively. For the purpose of this article, 8 common areas of focus for improvement in order to reduce cost and improve quality will be reviewed for discussion.
Although the promise of interoperability has been around for many years, progress has been slow. Disparate systems, independent hospitals, specialists and primary care providers are stuck in silos as incentives to work together are not fully developed. Even hospitals, specialists and primary care providers now in the same group because of acquisitions and mergers face the same technology and operational challenges with integration required to effectively coordinate care.
Med reconciliation tends to cause issues for just about all groups providing patient care. For many patients, the complexity of the lists due to shear length, adjustments due to procedures, formulary assignment, patient confusion and unauthorized discontinuation present challenges even for those providers and staff who take on the task of reconciling the med list. Operationalizing the process is difficult because of the multiple sources that feed the medication list: specialists, hospital discharge meds and primary care as well as understanding what constitutes the source of truth at the time of reconciliation as well as making the updates correctly in time allotted.
Evidence Based Guidelines
To get 2 providers to agree on protocols within the same practice and location can be challenging enough. Getting widespread adoption of evidence based guidelines is another story. Many organizations have not implemented the governance, operational support nor technology to support evidenced based guidelines that change with regularity.
Population Health Management
A critical component of improving quality and reducing costs is showing promise now that we have the technology to capture and mine useful data for providers and care coordinators. Still the cost of these systems, including running them, as well as the challenges operationalizing the processes required to standardize data collection for data that can be relied on and easily mined.
Alignment of Financial Incentives
The implementation of ACO, PCMH, PQRS and MU programs are steps in the right direction as we move from fee for service to fee for value, but fall short of removing existing incentives to over-utilize services like surgical care which continues to account for approximately 50% of hospital expenditures. A small percentage of ACO participants (about 10%) have targeted the reduction of unnecessary surgical procedures as a high priority Health Affairs. Building on the existing incentive/penalty programs and further refining the payment model with incentives that go farther to reward effective care coordination and improved outcomes with respect to quality and cost containment are still needed.
As patients, we should be held accountable for the elements in our care plans that we can help manage. We can’t control our genetics, socioeconomic upbringing, many types of accidents and other components, but in many situations we can take actions to avoid high risk behaviors as well as follow evidenced based instructions for preventative measures and to support the management of our acute and chronic conditions to improve our outcomes. When there are reasons why a patient may not comply, adjustments in the care plan or strategy may be necessary. Car insurance companies tend to "reward" good drivers, maybe health insurance should more aggressively reward patients taking an active role in supporting their care plans. If we expect evidenced based guidelines to be implemented by providers, perhaps we shouldn't shy away from encouraging patients to follow them.
Improving Payer and Provider Relationships
When payers came into the picture initially, they had great relationships with providers because the payers gave the providers what they needed to provide care from a reimbursement standpoint. As costs have skyrocketed, the relationships have unexpectedly become more adversarial where both sides fight to keep more of the pie. It has become a zero sum game and change is required to further improve the relationship to meet collective goals of improving quality and reducing or containing costs. To affect change for the better, all stakeholders need to come to the table together and leverage their resources effectively.
End of Life Care
The majority of patients want to receive care at home at the end of their lives, yet nearly 80% of patients die in a hospital or long-term care facility. (http://www.apa.org/pi/aids/programs/eol/end-of-life-factsheet.aspx) This is a significant discrepancy that requires continued focus. There are payers and providers that have implemented programs to better support patients at home at the end of their lives to reduce hospital days as well as hospital and nursing home admissions utilizing community resources, care coordinators and onsite care.