Even as it appears the combination of distancing, treatment and vaccines is helping to return society at large to a more normal footing, questions associated with quality, cost and access to care continue to vex the entire healthcare ecosystem. With a significantly stressed and strained provider landscape, how will the healthcare economy respond?
Following the pandemic, many health systems, government payers and health plans will resume focused investment in value-based care, including risk-based contracts, to create incentive structures for overall cost reduction and quality improvement. Given the massive scale of healthcare spend, all parties recognize there is opportunity to improve quality while reducing cost in a manner that benefits patients, providers and employers/health plans. Often, the work associated with making this shared benefit a reality includes cohort identification, outreach, care management and care planning carried out by the healthcare provider.
For providers to succeed in this new reimbursement model, a flexible data-driven foundation is required to understand dynamics inside of a patient population and intervene in targeted, high impact programs. Generally, the first question provider organizations ask is simply, “Which patients should we actively manage to see maximal impact on quality and cost?” For example, with a chronic disease like Congestive Heart Failure (CHF), expensive ER visits and/or readmissions following a procedure can be significantly reduced if patients adhere to prescribed medication instructions. Leveraging the system’s health data via on-demand analytics tools, health systems can define which patients are most likely to misuse or underuse medication based on medical history, social determinants of health and medication type, in addition to a litany of other factors. Understanding which patients pose the highest risk will help the system prioritize outreach to focus on the right patients. In the case of CHF, readmissions for Medicare patients carry a cost penalty to the health system and ED visits often carry negative profit margins. The lessons of this example can be applied to chronic disease, procedure follow-up and preventative care use cases to drive quality, reduce costs to patients, employers and health plans and improve economic performance of the health system.
After defining the right cohort, health systems are increasing investment in coordination and care management staff and tools to perform outreach and meaningfully impact patient behavior. In the CHF use case, upon understanding which patients are most likely to benefit from outreach, provider organizations are leveraging technology to best segment those cohorts and are beginning to experiment with types of outreach, messaging and program enrollment. Flexible technology allows health system to differentiate between high and low risk patient populations. For example, it is imperative to identify and manage the recently diagnosed CHF cohort with significant comorbidities, because they are more likely to require active care management and home visits. Whereas, a cohort of patients with CHF for more than a year with a history of medication adherence, who maintain a regular office visit with their cardiologist and/or a lack of significant comorbidities, are going to require less management within the health system. Identifying populations in need and focusing on factors that improve retention and behavior change will lead to better performance in helping populations manage disease and reduce overall utilization.
The environment for patients and providers is extremely dynamic. Breakthroughs in new treatment and therapeutics are announced at a fast pace across almost all domains in medicine. In the cohort identification and care management process, providers are increasingly leveraging IT platforms that can organize data to dynamically explore what works and what may need to be removed or refined to support the flexibility required to manage through so much change. Ability to explore, speed to access and data model flexibility are defining the winning platforms for providers and provider networks.
The work ahead in healthcare is fundamentally based on people, process and technology helping to serve patients, families and communities in times of great stress. Following a ravaging pandemic, the industry focus on higher quality, increased access and reduced cost is pushing organizations toward value-based care models. To fulfill the mission of elevating post-pandemic care, providers will need to increase their investments in technology and best practices that improve VBC based population health activities like cohort identification and care management.