While fee-for-service models offer little accountability for health outcomes, more and more providers are looking at new fee-for-value models that reward their ability to deliver higher-quality care with greater efficiency. However, succeeding in new value-based payment models means provider organizations must adopt new approaches to delivering care and engaging patients. Population health management and registry tools, for instance, can help providers understand the overall well-being of their patients and better address chronic conditions.
Health Data Management recently brought together a distinguished panel of health IT executives to discuss the question of whether the healthcare industry as a whole is ready for accountable, patient-centric healthcare and what stakeholders need to do to partner, collect and arrange patient information to realize the vision of a truly patient-based, value-oriented healthcare delivery system.
Roundtable participants included Vishal Agrawal, M.D., president of Harris Healthcare Solutions; Maureen Gaffney, senior vice president of clinical operations and chief medical information officer of Winthrop University Hospital; Joe Kimura, M.D., deputy chief medical officer at Atrius Health; Stephen Martin, Jr., executive director of the Association for Community Health Improvement at the American Hospital Association; Micky Tripathi, president and CEO of the Massachusetts eHealth Collaborative; Dave Whitlinger, executive director of the New York eHealth Collaborative; and Noland Joiner, chief technology officer at MarkLogic, the event sponsor.
Greg Slabodkin, HDM's managing editor, moderated the roundtable. What follows are edited excerpts from the discussion about the challenges of transitioning from a fee-for-service to a quality-based reimbursement care model.
SLABODKIN: Although the concept of patient-centered care developed before healthcare reform, are we now finally on the cusp of change as we enter a world of fee-for-value and population health?
JOINER: Theoretically, from a policy point of view, I think we might be close. But in terms of actually implementing it-the underlying technology or the underlying processes that need to be in place-I think we are far from it. We had a run-up in terms of everyone implementing EHRs and EMRs, but we didn't stop to think about how we were going to use them, how we were going to embed them in our overall processes across our organizations. So we need to take a step back; we're going to have to figure out how to put those systems in place so we can use them effectively.
The next piece is figuring out how we share data. You can't, in fact, drive patient-centered healthcare unless you're able to share data across the healthcare ecosystem. I think we're a long way from that.
AGRAWAL: I would build on that. I think the factors we look at are the business model itself and the pace of change of the business model. There is still a lot of money to be made in the fee-for-service world, and that's driving subsequent behaviors. Hospital systems are struggling with how to dip their foot in the fee-for-value world, while retaining most of their profit in the fee-for-service world.
WHITLINGER: I completely agree. If you look at the state of New York as an example, around 6 million people are going to show up in Medicaid. And that number is going to grow because of the Affordable Care Act. There is an $8 billion waiver on the table to encourage Medicaid recipients and participating providers to transform into a new healthcare delivery system. But that's a massive shift that is likely to take at least five years. Even then, you're only looking at a third of the marketplace. And there isn't a guarantee yet, from a payment-reform perspective, that the commercial world is going to follow suit-that the world is going to be a patient-centered home.
GAFFNEY: I think we haven't really taken into consideration the cost the providers will incur to build the infrastructure needed to manage what the expectations are. We have to ride out the fee-for-service train to get the revenue we need to put that infrastructure in place. And we still have these conflicting consensuses, conflicting agendas. If you were to talk to a physician or any other provider, they would all say, "Yeah, we want to take care of the patients, we want to have the information, we want to be able to know our patients well enough to be able to take good care of them." Yet, the only way they get paid is if they see more patients more quickly.
Also, we're telling these organizations, you have to do it cheaper. And they're coming back saying, "But I need new information." And then when we say, "Well, we'll give you the information," they respond, "How do I focus that?" There is a lack of confidence even in the data they are receiving.
KIMURA: There is a lag in terms of the technology or what we even know is effective. So it's one thing to be pushing down the cost curve, saying you need to do prevention. But we still rely clinically on some very old-school things. The science has to start to catch up. And that's a challenge.
GAFFNEY: Often I feel like I'm MacGyver, trying to make something out of old stuff and then also make something new out of old behavior. And it's very, very challenging. And I agree wholeheartedly that the industry, the vendor side, has to catch up to what the expectations are and to give us tools that we can use.
MARTIN: The world our healthcare delivery systems are living in-fee-for-service-is confusing. It's causing a lot of hesitation.
Will policymakers wait for the results to see if the new models actually deliver the results we want, the savings we want? It could take five years. It's messy, it's gooey. So will we wait or will we ride that train to bankruptcy?
And then, the other point, as Noland Joiner was alluding to, is that we're data rich, but information poor.
In this mad rush to get the EHR online, we kept saying, "Oh, it's going to be a continuity of care, a straight line." But, I heard a colleague describe the patient experience as a constellation. They're going to hit a pharmacy that delivers healthcare. They're going to hit a wholesale big box store to get drugs. They're going to go to a specialty-care facility for some treatment. Are our information systems bringing that data together? Are we capturing all of the information needed to make decisions?
AGRAWAL: I would say that we often use the term "EHR," electronic health records, but what we really have is an EMR, electronic medical records. And I think the H and the M are significant. We capture medical information that's often in a specific provider setting that's either vendor dependent or device dependent, it's not patient-centric. So until we shift from an EMR to a true EHR-that's patient-centric, that's a health record that includes other things outside of the clinical informatics-we are a ways away from a true patient-centric model.
TRIPATHI: It's not a technology thing, that's a business thing.
GAFFNEY: I think it is technology, too.
TRIPATHI: Well, the business drivers drive the technology at the end of the day.
Getting back to the original question, though, I think there is a false presumption out there that value-based model is a single thing. It's not. It's 25 different things right now-there's no single model.
And even in this conversation we threw out the terms accountable care and patient-centered medical home, as if those are two of the same things, which they are not. Atrius and other organizations have done a fine job showing that they can keep quality at least constant and shift down the cost curve.
It's not entirely clear at all that the patient-centered medical home is ever going to accomplish anything on the cost side. There is a real lack of evidence that it will. It might deliver on the quality side. And that might be fine societally.
We're investing more money for higher quality. That might be a good thing for us to do. But there is a lot of variation across the country and in different models.
MARTIN: When you say patient-centered healthcare, I think it means a lot of different things and a lot of different types of data. And when I look across the healthcare ecosystem I don't know if I see any consistency as to what that really means. And that's troubling, because you realize everyone's throwing out that term, but it doesn't necessarily mean the same thing to different people.
TRIPATHI: Is that a bad thing?
MARTIN: I don't know if it's a bad thing. But I think if you want technology vendors to enable that, it is a bad thing. A lot of them are not agile or nimble enough to pull together a platform that's going to allow you to be able to take in data here, there and everywhere when you need it.
KIMURA: That's because we always talk about IT infrastructure and then the operational workflow that it's trying to support. And I think many of us are trying to figure out the right operational workflow to optimize our efforts. Think about outcome measures-getting people to take their medications, getting them to come in and educate themselves-it's still kind of new. Maybe we see Geisinger is doing it better, maybe Kaiser is doing it better, maybe the Cleveland Clinic is doing it better. There's still a lot of experimentation out there. And so we're constantly changing our models. And that makes our vendors really unhappy.
GAFFNEY: It's interesting we've been talking about patient-centric care. But when we speak to patients about patient-centric care, they see it as a hassle. We have technologies that we plugged in to try to help with patient-centric care, and we've added layers to their experience. And then the insurance companies, to lower costs and to make sure there's medical necessity for testing or whatever is being ordered, add layers and time to their day.
The providers hear about all this when the patients come in. And the providers are being forced down this route. Yet they haven't bought into the value of it. Do we even know if it really works? Does it really translate to patient-centered care with better outcomes?
AGRAWAL: I think the jury is still out. I don't think it's clear yet. But that's absolutely the right question: Long-term, is this a good thing? If patients don't have the information to make good decisions or if the information they receive is not presented in a meaningful way.... For instance, if you're a cancer patient or a potential cancer patient and you get a test result that says it's negative, well, that's actually a good thing in a clinical context. But a patient could interpret a negative result as something bad. So, you have to understand the recipient of the information. How they are going to interpret it? We haven't transformed our health systems to do that.
GAFFNEY: The data has to be meaningful for the provider. I can tell you that the doctors, when they get all the information, most of them don't want to look at it because it's too much information. And it's not presented in a way that's meaningful to them. It's not in context to what they are seeing the patient for. And they are frustrated, because we keep saying we're going to give you more. And what they are getting is checked boxes-not necessarily the story of the patient. And each individual human being is more than just the check in the box, or the templated version of their encounter.
How do we get the technology to support the patient's story? Not in a redundant fashion, where we have to look through that they're allergic to penicillin five times. I mean, they lose confidence in the data then.
MARTIN: And on that point, do they have confidence to tell us that story, which is the full story. So right, that information on that screen tells me this, but that particular patient is holding back that one key component that the primary care physician is never going to know or may not be trained to know how to ask.
GAFFNEY: And the patient doesn't know to share it.
SLABODKIN: This raises an important question: Are patients ready to be at the center of care?
GAFFNEY: And are we ready as providers to allow the patients to be involved? We want the patient to be compliant, we want their BMI to be under 28, we want their hemoglobin A1C to be below 6-all of these measures. But what if the patient doesn't care about it? And we, as healthcare providers, whether it's organizational or individual, are being held accountable for patients' behaviors that we don't really have that much control over. And should we? We're crossing lines now in regard to patient rights.
In some cultures being a little overweight is a good thing, it's considered positive. And who are we to say, "Doctor, shame on you, because you didn't get that patient down to the BMI that the government has determined to be the best BMI." We're struggling with this in our communities. At what point are we being intrusive in regard to the direction we're giving a patient? We want them to stop smoking. We've done a wonderful job getting people to stop smoking. But there are some people we are just not going to get to stop smoking.
KIMURA: That's where the whole field of shared decision making is the critical element. Yes, we have guideline-based care that we created all of the quality measures for. We measure everyone uniformly across populations. But we know that when you drop down to the individual level, sometimes those guidelines are very inappropriate. You actually do not want to follow them.
KIMURA: So given that, and knowing personal preference is there, and knowing you're actually going to be paying for this anyway, the ability to capture the shared discussion of what mutually has been decided is the best thing. But then you need an infrastructure that can capture that-because right now we can't measure that at all.
GAFFNEY: And you need time with the patient to do that.
JOINER: I believe that in order for us to really get consumers involved, data collection has to be pervasive. The fact of the matter is that I can collect a lot of data without a patient knowing about it. Think about it. The minute they walk into a Walgreens, the retailer can collect data, which can be tied into Facebook or whatever. Retailers can collect all kinds of phenomenal data.
If we build policies and technologies around having a consumer be an active participant, I think you may or may not get participation. On the other hand, if you make it pervasive, I think that turns out to be a problem.
WHITLINGER: So when they walk into Walgreens and you're capturing that they bought four liters of vodka and a cartoon of cigarettes, that's what you want to try to affect?
JOINER: It's not that you want to affect it, but you do want to know it. You want to know it when a patient is sitting in front of you. Maybe you don't know what they purchased, but maybe a notice comes up that they have an ineffective lifestyle.
GAFFNEY: But we're crossing lines of privacy, I think.
AGRAWAL: Well, as the "health whisper" becomes more and more prominent, those behavioral determinants are going to be so essential to managing true population health. And you are right, there will be people who no doubt want to prohibit any type of cookie, so to speak, into what they are buying. But there will be a segment of people who are open to that.
I think there is a generational shift here also. There are technophiles; there are technophobes. One thing we know about consumer markets is they are very segmented. We're going to see different cohorts of the technophiles versus the technophobes, the privacy advocates versus the free information people who post knee deep on Facebook.
And we're going to see an explosion of data as well. It's just a matter of tailoring our informatics tools, tailoring our business models, tailoring our health plan designs in how we outreach to those individuals to meet their specific needs.
KIMURA: I think another driver is that we're never going to have a big enough delivery systems to take care of all the needs of our elderly population. Our ability to hire more doctors, nurses, pharm techs, pharmacists-you name it-is limited. The patient is going to be forced to become an active participant, unless they change their expectations around health.
If they are seeking health in the classic way, they are going to get stuck, because they can't get the sort of reciprocal care from the delivery system as we know it.
So how much of the Home Depot model of healthcare can you get to-where they have access to tools and, for 80 percent of their care, they don't see a physician or a nurse. They just take care of it. If I can do that safely and effectively, it optimizes everything.
GAFFNEY: I think we have to accept, too, that there are other things outside of accountable care, patient-centered medical home impacting healthcare behavior. The urgent care center phenomenon is probably one of the most dramatic catalysts of change right now for healthcare delivery systems.
We have a generation-even within my own home-that does not value a primary care physician. It's an immediate-relief mentality. With an urgent care center on every corner, they can get their antibiotic, they can get their x-ray, they can get whatever they need and feel better and move on. So how do we start changing that, getting the technophile generation to also value a primary care physician?
We have to start thinking about that generation. Unless we get them engaged in a healthcare-system type of thinking instead of that immediate fix, we're going to have problems later on.
MARTIN: We're asking our patients to come back and what we have to do is redefine, help them understand that the medical home is their home. And when we train them to think that way, it will allow us to accomplish a number of things.
The other point is that we need to train our consumer, our clients, that we want them to be as healthy as possible when they engage the most expensive part of the healthcare delivery system. What we've been doing is delivering sick care when we should be doing well care. So if someone walks in for a $20,000-30,000 procedure and we know their outcome would improve if they just lost five pounds, then we could reschedule the procedure and tell them to work on losing those five pounds. Then, on the back end, we're not dealing with readmissions, we're not dealing with other complications that have nothing to do with the experience at the most expensive part of the healthcare delivery system.
I've heard a lot about segmentation, but we're going to have to come up with a lot of different strategies to meet the different segments.
GAFFNEY: We're sort of in a schizophrenic crisis right now, because we have the tools and the technology that promotes test scoring, but yet we're saying that the way to really get to patient-centered care is to get away from test scoring and really look at the whole picture.
How do we blend those two things together and how do we bring back critical thinking into the healthcare space, because we are struggling with that even with the design of our EMR? There are demands for more and more clinical physician support, but yet when that system goes down nobody knows how to take care of the patient.
MARTIN: Well, that's what we were saying, the system is paternalistic, and we need to sit here and say parts of our system have been very egotistical, very "this is me." Okay, so now we've paid that price.
The health system as a whole is going to have to agree that we all have a common stake in this. We're all going to have to agree to come to those common solutions for those uncommon results.
Everybody is just asking how, at this point, do we work better with each other, because we've figured out that we can't do it alone.
WHITLINGER: But some hospitals' way of delivering a particular set of services may be better than the guy four doors down. And they're going to try to prove it seven ways to Sunday. And they will never adopt what someone else is doing no matter what.
MARTIN: You're speaking around the forces that laid this groundwork.
GAFFNEY: So we circle right back to the business model.
TRIPATHI: But maybe with provider consolidation, what you're describing isn't a bad thing, because people start voting with their feet. So I'm going to get care at Atrius, because they are multi-specialty, and I'm willing to sacrifice the best-of-breed approach.
My father was a primary care physician-internal medicine his whole career in a fee-for-service world. When I told him I had a knee problem, he said, "I know the best knee doctor in Boston." But I told him I'm going to go to Atrius. And he wondered why I would do that. Well, because as a system, they will give better care. So brands start to become more important. And I think that's what patients start to respond well to, not quality measures.
MARTIN: But it also has to do with the patient experience. Patients want some kind of connection with you to come back to you.
For those institutions that want to hold onto the old model, the question is will they survive. If a doctor has better quality metrics, that doesn't mean anything. They like how an individual treats them.
WHITLINGER: This is a very interesting conversation, because quality metrics of course have been elusive forever and I think they are going to continue to be elusive. The community doesn't want to be measured because we're going to have some winners and losers.
MARTIN: But fortunately we have some other players in there that are going to force things.
WHITLINGER: Good luck to them, I think it's God's work. Let's hope they succeed. I don't bet on it.
MARTIN: Clients like Walmart, which are stepping into this health space and saying not only that they're going to try to drive the cost down, but they're going to do it even better and they're going to drive you out of business. That's my observation.
WHITLINGER: They're not going to do knee surgeries.
MARTIN: But they're offering health as a loss leader, because they want you to buy tires and they want you....
GAFFNEY: They want you to come in the door.
WHITLINGER: They're not going to go too much deeper than the common cold. They're not doing appendectomies in the middle of the store.
MARTIN: But now that you've come in, could they set up the model for $4 prescriptions? Now you're in the retail chain. Now all I've got to do to keep you in my network is to figure how do I take your information and give it to the specialist over here in my network. And that's what they're trying to figure out now.
JOINER: You're talking about the power of the adjacent market to change the culture. You know, most of the conversation has been provider-consumer, we haven't really talked about life sciences, net providers, all these other organizations. And there is a huge, huge buffalo in the room-innovative startups. I believe that the data these other adjacent organizations are now capturing will, in fact, have a heavy influence on providers and consumers-and how fast the cultural shift happens.
SLABODKIN: Surveys overwhelmingly show that patients want to be prescribed an app and yet it's the doctors themselves that are not convinced. I'm struck by the fact that consumers actually might be leading the technology drive, whereas more conservative physicians and others clinicians are hesitant.
JOINER: You've got to think about it, right. In a 10-year span, we've gone from faxing sheets of paper to sending them online. Boy, if I could wave a wand, go back and ask you guys to define the workflow.... Then we could have defined the underlying technology and data requirements. Unfortunately, we didn't do that. We ran, and now we have EMRs and EHRs. We have all of those things. And if I were on the other side of the table I would probably say, "Hey, wait a minute, you're pushing too many things at me too quickly, and I can't ingest what that really means."
GAFFNEY: And we're backing into it, instead of letting clinical workflow design the technology. And that's been a frustration for a lot of providers. And we know that every practice runs a little differently. Good, bad or indifferent, it is what it is, it's the physician's world. In our area, we have large practices and we still have some single practices. And to get them to adopt this technology and make it work for them in their current environment is very, very difficult. But I agree with you, I think that it has to happen.
We have to somehow streamline it.
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