Tag Archives: value-based care

Is Value-Based Care Coming to WC?

At the WCRI Annual Issues and Research Conference, Randall Lea MD from Alice Peck Day Hospital discussed value-based care. The hospital has been working on a study of value-based care and the workers’ compensation industry. Value-based care has been gaining traction on the group health side but not in workers’ compensation.

Study participants included medical providers, payers and regulators. The hospital found that none of the study targets were overly enthusiastic about the concept of value-based care in workers’ compensation. Survey respondents expressed doubt the model would catch on because of regulatory constraints and a lack of understanding by market participants.

See also: 5 Ways Data Allows for Value-Based Care  

A major theme of the survey responses was the need for a change in the regulatory environment to allow for a value-based care system. All stakeholders agreed that without full employer control of medical choice such a model could not function. Providers also pointed out that they would need to be free from utilization review  for this to work. You cannot hold providers accountable for outcomes and at the same time limit what treatment they can do.

Another challenge of the value-based model in workers’ compensation is that outcomes are gauged by more than just medical outcomes. Return to work and impairment are concerns in the workers’ compensation area that do not exist in group health.

Regulators were concerned that a value-based model needed to provide incentives to all stakeholders, medical providers, payers AND injured workers.

Another major concern of study respondents was payment/reimbursement. A value-based system needs to provide prompt and fair reimbursement to medical providers. Existing fee schedules would need to be eliminated. Providers were also concerned about having the required volume of patients to make a value-based model worth their effort. The study groups had wide views about what types of payment models would be preferred. Options included bundled, Medicare like, shared risk and fee for service (FFS).

Study participants were also concerned about how outcomes would be measured. For example, is an actual return to work needed, or does a release to modified work achieve the outcome? The medical provider has no control over whether the employer will provide modified work. There are also concerns about how the patient’s satisfaction would affect the outcome measurement. There could be conflict between what the payer seeks to achieve and what the patient wants in terms of care. A good example of this is the challenge around opioid medications.

See also: 3 Key Points on Value-Based Care  

The conclusion is, do not expect to see true value-based care systems in workers’ compensation any time in the immediate future. There are too many regulatory constraints that must be overcome.

5 Ways Data Allows for Value-Based Care

As the healthcare industry moves toward value- based care, reimbursement will be tied to quality outcomes achieved. While the concept is simple enough, operating under this model brings some complications. Advanced analytics can help healthcare organizations understand their current situation, what might happen in the future and what actions they should consider.

Below are five ways that healthcare organizations could accelerate their success with their value-based initiatives by leveraging advanced analytics:

#1: Get the full picture with a 360-degree view. When attempting to understand patient/member behaviors, trends, habits and actions, it is critical to bring together a variety of data sets to create a complete, 360-degree view of each member/patient and provider. By accessing data such as medical claims, pharmacy claims, enrollment, health risk assessment (HRA) and survey, lab and biometric, EMR/EHR, socioeconomic, etc., healthcare providers can make sound decisions based on facts to improve patient/member outcomes.

#2: Understand populations. Knowing the makeup of the population served is critical to the success of value-based initiatives. An organization must understand the clinical and financial risks that exist across their populations to implement programs to manage that risk. Analytics can help to categorize various patient populations as high, medium or low risk. Once an organization has identified where the risk rests today, they can use predictive analytics to predict where it is likely to surface in the future. With this knowledge, healthcare organizations can make more targeted interventions.

See also: Strategies to Master Massively Big Data  

#3: Allocate resources. All healthcare organizations are managing their business with limited financial and human resources. By leveraging advanced analytics, those resources can be focused on areas that promise to produce the greatest return on their investment. For example, by assessing impactability (Impactability is predicting and identifying prioritized opportunities that have the greatest clinical or financial outcomes), healthcare organizations can determine how likely it is to reduce emergency department visits or in-patient utilization if care gaps are closed with specific patients/members.

#4: Avoid costly procedures and services. As healthcare organizations strive to deliver next-level quality care, they will begin to pivot to precision-level, personalized care management opportunities. One such method to raise the stakes is identifying the best care choices when working with conditions that lend themselves to preference-sensitive treatment options. This occurs when patients present with conditions or ailments where there are no definitive clinical guidelines and a variety of potential treatment options exist. For example, when patients present with knee or hip pain, surgery is not the only option. Indeed, providers, in some instances, could treat the pain just as, or even more, effectively with other less invasive options. Quality, cost and satisfaction can all be improved by providing the patient with education regarding more effective, less invasive treatment options with conditions such as uterine fibroids and endometriosis, bariatric conditions and low back pain. By understanding who is at high risk for these types of potentially avoidable procedures and knowing the total episode cost as well as the remaining time to use a less invasive option, care providers have the opportunity to reduce the number of invasive, costly procedures.

#5: Deliver personalized care. In most cases, healthcare providers find that delivering personalized care results in more effective care. But nearly all care management programs strive for personalized, effective care. So, what is the answer? The answer may lie in developing consumer types across populations. Consumer types is a method of categorizing patients/members based on like attributes such as age, gender, education, income, etc. By knowing the various consumer types and their attitudes that make up a population, healthcare organizations can develop, evaluate and market care management programs to the most effective patients/members. For example, if a diabetic patient lives in a food desert, it would be difficult to get them to comply with a healthy eating plan. Or, access to transportation may be a barrier to adhering to a medication plan, as patients might be required to trek to the post office just to pick up their prescription drugs.

See also: 10 Trends on Big Data, Advanced Analytics  

At the end of the day, care givers seek to gain insight into not only what has happened, but what will happen and then what should I do about it. With so many competing priorities, it can be extremely difficult and overwhelming to know where to begin. By using advanced predictive and prescriptive analytics within daily workflow, healthcare organizations are able to confidently allocate resources to focus on high-value opportunities that will improve both clinical and financial outcomes.

Interested in taking a deeper dive? Check out our webinar titled 5 Ways to Use Data for Advanced Analysis.

3 Key Points on Value-Based Care

One thing we know for sure is that the “train has left the station” when it comes to healthcare reform. No matter what party you follow, or policy you like to support or ignore, the healthcare industry MUST change to a value-based platform. What that means is that, while the financial infrastructure of receiving healthcare used to be a pay per visit/test/hospital stay, etc., it is moving to a payment system based on outcomes — or “value,” as we like to brand it, because it sounds better.

What that means is a radical change for any associated industry, including, foremost, insurance companies, the ultimate risk bearers. All insurance executives rejoice, right? The idea of offsetting the risk to the providers responsible for the care of the patient sounds like one heck of a business strategy. Is it, and what does this mean to the insurtech conversation? My point of view: A LOT.

Keep reading. I promise I’ll keep it short…who has time for long articles? My goal is to get your thoughts charged around how this affects you and give you an idea or two

It may be relevant to know that I am a long-term provider advocate, having been the chief administrator of a large OB/GYN group while I cut my teeth in healthcare and having served 10 years as the CEO of the then-largest and most prestigious primary care/internal medicine group in the region. I can tell you that this movement is the RIGHT thing to do, and I can also tell you that it is complex, expensive and overwhelming.

See also: U.S. Healthcare: No Simple Insurtech Fix  

The days of small practices with time to actually spend with the patient and not face the computer (and be buried in endless paperwork burdens, digital or not) are seemingly gone due to the demands of the system. If you have been to a medical facility as an actual patient in the last year, (and I hope you have been for at least your annual physical), I am confident that you saw this first-hand. Your experience likely included witnessing every staff member from the front desk to the clinical team inputting data of all sorts into the computer, and perhaps not having enough time asking you how you “really” were. (READ: COULD THIS BE A RISK ISSUE?) What you may have also noticed is that you probably had to pay more than you expected. Gone are the days of the $10 co-pay. The movement to high-deductible plans has changed the game completely. So what does this mean to you?

In the March 2017 article by Sam Evans, “The 10 Trends at the Heart of the Insurtech Revolution” #1 was that “Insurance will be bought differently,” (also sold, underwritten, etc.) The demands of the medical community and the patient are under attack with what seems like an endless need to capture and understand data, learn, develop new payment infrastructures and oh, by the way, be transparent so everyone knows exactly what is going down. Dr. Halee Fischer-Wright (the CEO of the national Medical Group Management Association and a physician) rants in her new book, “Back to Balance,” about this early and often. She says that “according to the MGMA study, it costs the average practice $40,069 per physician per year to just manage and report quality measures. For a relatively small practice of 10 doctors, that’s more than $400,000 per year. Not to improve on measures–just to report.” WOW- She continues with story after story and urges us to consider how to get a better balance and to put the patient at the front of the conversation. It’s a good read, and I’d recommend it if you have clients in the healthcare space.

Three key points to digest:

  1. Value-based healthcare is here to stay: It changes everything for every healthcare-related client you have. If you are on the risk side of the business, understanding how the new systems are creating learning opportunities, barriers and downright sinkholes that your clients may fall into is mission-critical. (I didn’t get into it, but clearly the issues with technology and the added complexity of detailed health information is the patient privacy/hacking issues… oh, yes… another policy that healthcare providers need to buy or buy more of to protect their patient information.)
  2. The pure cost of healthcare is increasing due to many competing factors, and most of that cost is SHIFTING to the patient. This means insurance is being bought differently. This means that new insurance alternatives are popping up, (concierge, direct primary care, employer-sponsored, etc.) and that there are NEW customers for you to understand and educate on the role that insurtech plays in their world. Many of these are NEW AND INNOVATIVE companies that need deep knowledge on these matters.
  3. Anyone who has physician/hospital clients should be VERY AWARE AND EDUCATED on every aspect from risk assignment, to education, how technology affects patient care and ultimately malpractice, financial pressures- I would say EVERYTHING is up for review and understanding.

See also: Healthcare: Need for Transparency

If as an industry, we are to be the BEST PARTNERS for our clients, then we must do more than have a cursory understanding of the multiple issues with value-based care. If anyone needs a tutorial, I am up for helping out!

Hey, Pharma! It’s Time for a Change

As Bruce Buffer, voice of the UFC, would say, “IIIIIIIIIIIIIIIIIIIIIIIT’S TIME!”

In this case, it’s time for big pharma to stop just defending its prices and to start to tap into the consumerism that is transforming healthcare.

Check out these stats (mostly from Google and Decisions Resources Group):

  • One in 20 online searches is for health-related questions.
  • According to comScore, health topics are the No. 1 search category on mobile.
  • 72% of people with pre-existing conditions searched for medical info online.
  • Half of all patients and caregivers already turn to digital channels to look up formulary or dosing information.
  • After a diagnosis, 84% of patients searched for options.
  • In a report by Decision Resources Group of 1,000 physicians, more than 50% reported their patients are more actively involved in treatment decisions — and these doctors called on pharma to support affordable options, provide relevant information and make online information more understandable.

The latest survey from Medical, Marketing & Media (MMM) shows 76% of pharma respondents use digital marketing, but the channel segregation below shows respondents devoted the greatest percentage of their marketing budgets to professional meetings/conferences and sales reps/materials. Digital channels — including websites, digital advertising and social media — lagged behind.

More surprising is that only half of both large and small pharmaceutical companies see the growth of consumerism in healthcare as an opportunity. But that’s EXACTLY where the opportunity for growth lies. To thrive in the new era of value-based care, pharma companies will need to change their marketing strategy toward partnering and will certainly need to focus far more on the individual consumer.

See also: Checklist for Improving Consumer Experience  

Trying to scare politicians away from lower-price reforms with the “It will kill our R&D” excuse is becoming the “BOO!” that no longer scares the grown-ups. Both 2016 presidential candidates, Hillary Clinton and Donald Trump, plan to stimulate price competition through imports — and there is bipartisan pressure to lift the ban on Medicare’s negotiating drug prices. Apart from trade groups and shareholders, high-priced pharma doesn’t have many friends.

Payer pressure is bad enough, but if you don’t get into the value-based care game, you are going to be on the wrong side of a very emotional equation.

Patients have greater financial burdens because of higher deductibles and greater cost-sharing requirements, with varying medication tiers. Providers are ever-burdened with less time, and, now, a greater level of risk is being put on them to deliver higher-quality care, better outcomes and greater patient satisfaction — all at a lower price.

Patients are not just seeking advice from providers. They are increasingly online, and at all hours. Plus, we’re going to start to see greater levels of patient-generated healthcare data with wearables and digital technology. And, as we have seen, half of consumers spend their online time on social media. (HINT: Tap into consumers’ behaviors and beliefs, show that you genuinely care and engage them in ways that let them feel as though you are part of their health team.)

The writing is on the wall. Consumers are practically screaming out what they want and need from you. Partner with wearable and EHR companies. Start developing ways to capture and interact with your customers — specific to individuals, at the best times to engage. Find ways you can partner with hospitals, physicians and affordable care organizations (ACOs) to get into their care pathway in ways that help them lower costs to patients and payers.

See also: Stop Overpaying for Pharmaceuticals  

Say “yes” to predictive modeling, big data, analytics, lots of testing and customer segmentation. “Yes” to retaining some of the traditional marketing. Most of all, become human in your approach. Put yourself out there and let people know that you are no longer on an island, separate from everyone else. Let them know your port and beaches are open to more boats and more people than ever before.