A New Direction
A New Direction
While the overarching missions, visions, and values of healthcare organizations have largely proven timeless throughout our industry’s evolution, the roles and purposes of our nation’s healthcare leaders have quite possibly transformed more than that of any other across professional sectors in memory.
This dichotomy, both ideological and practical, calls attention to an important distinction. While our organizations have traditionally focused on the macro-level ‘what’ of the business, our leaders have been challenged with delivering on the more focused ‘how’ to achieve those ends.
For example, countless organizations have the common ‘what’ threads of clinical excellence and compassion and patient satisfaction, among others, woven into their corporate tapestries. All the while, health care leaders are charged to navigate the ‘how’ which, not so conveniently, entails an increasingly complex and, sometimes, mercurial mix of patients, payers, and providers.
"The journey leaders will take to get their organizations on the path to accountable care will assuredly vary, but most of all will share commonalities in their potential road bumps (challenges), detours (approaches), and roadmaps (objectives)"
Enter Accountable Care, the most predominant and, perhaps, most challenging ‘what ’of our time. It is the concept whereby payers and providers collaboratively develop care models to facilitate the transition from “volume to value”, thereby delivering higher quality, cost-effective care. This new ideal represents a marked departure from the incumbent paradigm which can actually reward fragmented and reactive care as opposed to incentivizing proactive care management and wellness—a transition I sometimes refer to as the overall movement from “sick care” to “health care”. That said, these lofty ‘what’ goals are much easier said than done; and, our leaders are asked to execute on the ‘how’part of the equation, to turn the vision of accountable care into reality. This is and will be no simple feat.
Orlando Health’s Journey
The Central Florida marketplace has served as one of the country’s hotbeds for accountable care activity since the concept was birthed out of the Affordable Care Act nearly nine years ago. In that time, Orlando Health has embraced the seminal foundational concepts of value-based care and been a driving force for adoption and development of these models in our community.
Our health system’s efforts began in earnest in 2012 by virtue of partnership with the area’s largest primary care physician group; shortly thereafter, in 2013, Orlando Health launched the state’s first health system-led Medicare Shared Savings Program (MSSP) Accountable Care Organization (ACO) which delivered on its value-based aims in the very first performance period. In the years to follow, the organization would go on to stand up dozens of other value-based models including commercial payer ACOs, Medicare Advantage ACOs, the nation’s largest direct-to-employer model, and federal and commercial bundled payment programs, to name a few.
All told, through this portfolio of value-based programs, Orlando Health has generated more than $100 million in savings to its payer and employer partners while maintaining among the highest quality ratings on local, regional, and national levels.
Paramount to our organizational success was the formation of the region’s largest and highest performing clinically integrated network, the Orlando Health Network, in 2015. This network, now comprised of more than 4,300 providers, spans seven counties and covers more than 200,000 aligned patient lives. The ability to leverage this “plug and play” network across our myriad value-based contracts has proven to drive immediate cost savings, improve continuity of care, and generate better patient outcomes.
Many of the “quick wins” produced by the Orlando Health Network to date have been of the proverbial low-hanging fruit variety, such as reducing duplicative services and increasing preventive cancer screenings; however, the network’s leadership team has identified many more areas of opportunity to improve, each presenting their own unique set of challenges, along with exciting possible solutions.
As aforementioned, our leaders are charged with developing new strategies and operational models which consider all key stakeholders (patients, payers, and providers, among others) while simultaneously considering the complexities part and parcel of the United States health care system. As such, the journey leaders will take to get their organizations on the path to accountable care will assuredly vary, but most of all will share commonalities in their potential road bumps (challenges), detours(approaches), and roadmap s(objectives), as described below.
The Journey’s Potential Road Bumps
• Data Management. Probably the most discussed difficulty in all of accountable carecare relates to data management and the use of the data to manage populations. Typically speaking, provider organizations are not overly experienced in managing payer claims datasets; and, similarly, payers are not accustomed to working with large scale clinical data feeds. Amalgamating both clinical and claims data into a unified data platform is a major undertaking, including addressing all of the requisite data integrity and usability concerns. However, being able to get regular and transparent datasets shared between payers and providers is imperative to identify opportunities and drive change. To paraphrase Peter Drucker, if you can’t measure it you will not be able to effectively manage it.
• Migration Planning. Critical to the early success of any transition to value will be how leaders frame their shift from fee for service (FFS) to fee for value (FFV) and, subsequently, determine at what pace to make this transition. The juxtaposition of FFS and FFV does not have to a discordant one; in fact, driving value to payers often comes with the incentive of added volumes via increased network steerage and preferential benefit design. Thus, a harmonious transition is possible so long as an organization’s leaders embrace the concept of accountable care and thoughtfully stage their entrance into financial risk arrangements.
• Market Demand. Key stakeholders must be ready to embrace disruption for any real change to occur. A meaningful accountable care partnership has to show more than just appetite for change on one side of the table. Both parties, payers and providers, need to prepare for a new business relationship which is collaborative more than just in rhetoric and marketing collateral. If the initiative is one-sided, the probability for success will be greatly diminished.
• Provider Network. Establishment of a high value provider network, at all levels from primary care through quaternary facility-based services, will give the greatest likelihood for Accountable Care success. Though, the challenge here is, at least, twofold: (1) it is difficult to ascertain which providers drive value with limited access to cost and quality data, and (2) a high value network is inherently exclusive based on performance requirements which invites both potential provider politicking and possible member disruption (e.g., low-performing providers lobbying to be in-network, patients losing access to out-of-network providers, etc.).
• Patient Engagement.Creating coordinated and perpetual connectedness to our patients will be the next big frontier for health care leaders. As is widely published, an individual’s health is largely determined by the interaction of four factors: (1) biology, (2) behaviors, (3) environment, and (4) the use of health care services. As an industry, we have traditionally only focused on the lattermost factor, but to improve the health of populations we will have to find ways to engage with patients to improve the other areas of health. Moreover, addressing non-clinical components of well-being will be profoundly important given we know many socio-determinants sadly presentobstacles to optimal health, like someone having to decide between paying their utility billsversusrefillingtheir prescription.
The Detours To Success
• Data Solutions.In the last decade,countless data management vendors have developed new capabilities to ingest and curate “big data” in ways to help discern meaningful insights. Such capabilities as predictive behavioral modeling and patient risk stratification will help move the needle on care management efforts and resource coordination; this inspires a positive shift away fromformer anecdotally-inspired approaches for change towards true data-driven decision making. More recently, these companies have started broaching the socio-determinants field of care management, as well—some vendors even going as far as building in discrete fields to capture many non-traditional values like credit scores and patient proximity to public transportation and grocery stores.
• Experience Applications. Health care consumerism platforms, such as cost transparency tools, provider rating applications, and the like, will encourage more informed shoppersto be better fiduciaries of the health care dollar. By creating a more cost-transparent and experience-forward ecosystem we allow the patient to effectively “vote with their wallets” which innately inflects the cost curve. A marketplace predicated on value– higher quality, better experience, lower cost, or a combination thereof– will reward high-performing providers and cull the herd of poor performance. As a byproduct, prudent spending behavior also will force the industry to become more efficient as many wasteful services, traditionally revenues to providers under the FFS archetype, will be lessened to more tenable levels.
• Interactional Applications. Care management tools designed to create a more connected relationship with patients and families also show great promise for an accountable care-centric future. These new and emerging solutions will better enable providers to engage in care interventions closer to real-time, ranging from simple smartphone push notification reminders to more advanced remote patient monitoring devices. For many organizations adopting these tools, the sky is the limit in terms of deployments. The most obvious use cases are in the chronic and complex disease cohorts, whereby these technologies are leveraged to prevent condition exacerbation through increased monitoring, medication management, and health coaching. In other circumstances, organizations use these technologies to engage broader populations in healthy behaviors, such as smoking cessation and weight management. Finally, perhaps the most exciting (or scariest, depending on your perspective) emerging technology is geo-location triggered health care interventions, which prompt patients to engage in certain care activities based on their real-time proximity to services, specific care needs, and benefit design (e.g., pinging a patient to get their annual wellness visit when they are near their primary care office). Some may consider the uses of geo-mapping to be paternalistic; however, the interactional capabilities of these new technologies is opening up a world of possibilities to furtheringvalue-based agendas which must be explored.
• Provider Connectedness.While staying linked to patients is of chief importance, it is arguably as important to ensure the provider network is also highly connected to encouragetimelier, more efficient, streamlined care. Health care lags other industries in breaking down silos and connecting existingsystem resources. As probably anyone reading this already knows, there is a severe national shortage of primary care and behavioral care services. Availing technologies to ensure both better referral channels between existing resources is the first step many have sought to implement; the second phase then is creating more commoditized access, like those offered via telemedicine, to expand thereach of these limited services to many disparate locations. As such, considering a multi-prongedprovider connectivity strategy also helps better connect valuable but limited resources to our patients (e.g., licensed mental health counselors). This is a particularly salient topic given our nation’s opioid crisis, growing suicide rates, and widening shortage of certain primary care provider types.
The Shared Value Roadmap
To forge a better path forward toward more coordinated and efficient health care will demand strong leadership. Value itself is not a new concept, but the aspirational aims we seek to achieve require we stay the course on our Accountable Care roadmap.This process actually starts by thinking upstream of care delivery itself; it starts by thinking patient-centered whole-person health, including emotional, spiritual, financial, and psychological well-being. It starts by thinking about how to turn the legacy model on its head, and to move to a model in which our organizational incomes are dependent upon our Accountable Care outcomes.
Leaders will need to advance the notional ‘how’ concepts of Accountable Care in their organizations and usher their constituencies toward those tenets which align to our collective organizational ‘what’ objectives and values. The models of yesterday, while important andalways relevant, are inadequate to achieve the outcomes we charged with today. Today necessitates a reframingof our thinking on how to deliver true “health care”, which is an exciting opportunity for those driving these initiatives at their organization on each’s journey to Accountable Care, road bumps and all.