MedCity Influencers, Payers

What strategies will drive clinical excellence and improve access to care?

The epidemic of chronic disease requires prevention and continual intervention that brings about behavior change on a massive scale.

Hospital Doctor With Digital Tablet Talks To Male Patient

With the debate over healthcare reform and how to bend the healthcare curve creating deep divisions in the political arena, it’s hard to cut through the noise to refocus on those initiatives that we know just work. As a Chief Nursing Officer, I’m definitely not an economist that can evaluate the pros and cons of tax credits versus subsidies, but I do know one thing. Like most things in our economy, healthcare costs are governed by the same fundamental principles we learned in entry-level business class – supply and demand. Or, to translate into terms we all know as healthcare professionals, the healthcare system and coverage market is based on shared risk and utilization rates.

The sicker the population, the more we collectively pay because utilization of medical services is up. Nothing creates greater utilization and stresses the system more than treating chronic illnesses. Chronic illnesses now affect more than half of all Americans, and one in four has at least two chronic conditions. That is a staggering statistic when you stop and think about it, and it comes as no surprise that the associated costs of treating these conditions historically has cost as much as 86 percent of the entire healthcare spend in the U.S. This situation has clearly contributed to premiums rising 123 percent since 2000, so it stands to reason that if by addressing this part of the equation, we can make significant progress on curbing costs.

This is why it is critical that everyone on the healthcare continuum – providers, insurers, drug manufacturers, vendors/suppliers, community resources and the government – should be looking at new ways to promote more effective care coordination and collaboration programs. We are long past the days when insurers offered disease management programs that called and/or wrote to members with chronic conditions. These types of programs were way too costly and didn’t take into account the reasons why patients weren’t adhering to a program.

The epidemic of chronic disease requires prevention and continual intervention that brings about behavior change on a massive scale. So, what strategies will drive clinical excellence and better access to care? I believe we can see large-scale improvement in population health through deeper partnerships across the healthcare ecosystem. This will require cooperation from health systems and community or care organizations, collaboration between providers and payers, with a great opportunity for insurers to be in the driver’s seat.

Regardless of what we think we know about the healthcare reform debate, the movement to value-based payment for providers looks like it’s here to stay in Medicare and Medicaid, and it’s likely that insurers will co-opt many of these changes into the commercial market. That means that providers will be incentivized to improve outcomes, and I believe that this creates the golden opportunity for insurers to seriously engage with health systems and providers.

Health plans must look beyond a member’s care to understand the underlying parts of the patient’s life – their social determinants of health. We cannot treat an illness holistically and drive down costs collectively if we aren’t adjusting for risk factors that are as much a part of the patient’s life as their symptoms. In fact, many have posited that health outcomes for populations are often more determined by social factors than by the medical care they receive. Even HHS released a report to Congress that found that Medicare recipients with social risk factors fared far worse across the board.

The fact is that there are already some good examples of partnerships that are reducing costs by focusing on social risk factors. By bringing together payer, provider and community organizations, the Eastern Virginia Care Transitions Partnership reduced baseline readmission rates from 23.4 percent to 9.1 percent while lowering costs for Medicare beneficiaries with chronic conditions. Employing highly trained “coaches” that made approximately 26,000 in-home visits, the partnership addressed factors such as housing needs, transportation issues and behavioral health screenings to overcome some of the real drivers of illness.

Another promising area for collaboration specifically between providers and insurers is digital therapeutics, something that has seen a lot of investment recently. Digital therapeutics relies on behavioral and lifestyle changes, and because they are mainly online, data can be collected and analyzed as both a progress report and preventive measure. They also help reduce costs for healthcare consumer, because things such as virtual doctor visits require fewer resources. As high-deductible plans become more common, healthcare consumers are looking for new models, and digital therapeutics offers an intriguing method to manage chronic conditions. In fact, Kaiser Permanente reported that 50 percent of provider visits were virtual, and behavioral health is seeing even more rapid utilization. Insurers and providers should be investing in programs that either co-develop these initiatives or incentivize their creation.

Technology is driving a huge revolution in the care-delivery world, and innovative insurers are ahead of this curve. However, in many respects, these innovations have put tremendous stress on both insurers and providers. From electronic health record adoption to interoperability as a whole, the U.S. healthcare system – which is known for having some of the most advanced medical treatments in the world – is still having some late-adopter problems on the collaboration front.

The bottom line is that insurers and the networks they partner with should be investing in and developing partnerships that look at a modern-day patient’s life holistically. Right now, I’d surmise that no one is completely happy with the current cost trajectory, which means we all have a stake in this critical issue. As an industry we should look at better ways to address it together across organizational lines.

Photo: Getty Images

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