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Patients can’t do it alone

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   By Miles Snowden, April 2012

H04_ACOs_Optum_Snowden_90x113Hospitals and health systems hold the keys to enabling patient accountability.

Healthcare industry experts generally agree patients will play a key role in driving down healthcare costs with the advent of new models of accountable care, but enabling patient accountability will only be made possible with support and guidance from hospitals and health systems. While patients need to become actively involved in their own health and care, they can’t – and shouldn’t – do it alone.

Putting an unrealistic emphasis on the role of the patient increases the risk they will act against the advice of providers or delay proper medical care. For patient accountability to positively impact the delivery of care, physicians, patients and hospitals must develop a shared goal of achieving the best outcomes at the lowest possible cost. Once alignment is in place, providers will then need to implement and deploy technologies to stimulate patient accountability. For at-risk hospitals, the highest-cost individuals are those not currently engaged in the system and who do not consider themselves “patients.” Targeting these individuals with patient accountability strategies is critical to reducing costs for hospitals and health systems; information technology and services exist today that successfully support patients in upholding their end of the accountable care bargain.

There are three categories of “accountability enablers” that hospitals should consider as they adopt models of accountable care – demand management, population management and network management. These programs and tools reduce hospital readmissions, manage chronic disease and prevent primary diseases, benefiting both patients and provider organizations by promoting health and controlling unnecessary healthcare spending.

Demand management: Putting the brakes on expendable procedures
Hospitals and health systems often operate under the misunderstanding that in a risk-sharing environment, they will succeed by running the best clinical organization with the ability to perform the most advanced procedures. However, in addition to being reactive to patients needs, hospitals must implement strategies and resources to keep their at-risk population healthy, thereby reducing procedures. Reducing the volume of procedures performed has a direct financial benefit to hospitals and health systems when participating in ACO or other value-based contract arrangements. Two ways hospitals can use demand-management tools are to lower readmission rates and to reduce unnecessary elective procedures.

Reducing the readmissions of Medicare beneficiaries yields a robust return on investment, as the Center for Medicare and Medicaid Services (CMS) penalty on high readmission rates may be eliminated or mitigated. Hospitals should establish or enhance existing discharge programs to focus on maintaining their relationship with Medicare beneficiaries post-discharge, either telephonically or through home visits for as long as necessary to assure there are no barriers to appropriate home and follow-up medical care. New technology categories, such as home biometric devices and telemedicine, are available for providers to effectively limit readmission risk. These care-transition programs have proven to reduce readmission rates by up to 50 percent. Demand-management technologies support clinicians in asking simple but effective questions when patients are being discharged, such as: “Where will you go post-discharge?” “Are you certain any equipment or physical therapy has been arranged?” and “How can we reach you?” These interactions serve to establish a relationship that providers can continue remotely post-discharge to assure readmission risk is minimized. Discharge programs counter some of the system inefficiencies and better moderate unnecessary demand in the medical system, such as repeated trips to the emergency room.

In addition to readmissions, hospitals participating in ACO arrangements can deploy demand-management tools to proactively reduce unnecessary medical procedures. Elective surgical procedures may have a large, and sometimes unnecessary, financial impact on both patients and hospitals. Recent experience demonstrates that when clinicians presented patients with alternatives to elective surgery, one out of every 15 patients change to a non-invasive course of care. Through a demand-management system, hospitals can connect with patients prior to surgery to discuss the decision and recommend non-surgical or less-invasive procedures.

Chronic disease management: Driving good decisions from hospital to home
Under accountable care arrangements, providers can no longer afford to view their focus as only those in need of current treatment. Individuals with chronic diseases are high-cost, high-frequency consumers of healthcare, and effectively managing their care in a home setting is important for physicians to reduce unnecessary medical spending. By leveraging contemporary population health-management technology, providers can increase patient compliance by 20 percent.

Hospitals and physicians participating in accountable care-reimbursement arrangements are in a uniquely favored position to effectively apply care-management tools to address the specific health needs of their attributed patient populations. In general, the provider’s patient panel is living relatively proximate to the provider’s medical services facilities. This provides a distinct advantage over the traditional payer. Payers more often serve a more geographically diffused population. This difference allows providers to deliver more of their population health-management services face to face, in their facilities, during patient visits. This model, along with the physician-directed component of population health management, has proven more effective than models relying on telephone outreach from health coach operations centers.

In effective models of accountable care, providers will need to connect with patients not just at the point of care, but also with other attributed members in the community not currently using health services in the system. According to a commercial insurer’s 2010 population analysis, half of the high-cost patients had minimal to no engagement with the care-delivery system in the prior year. It’s important to identify and engage these individuals before they require acute care. Population management technologies require hospitals to partner with organizations that specialize in identifying and engaging individuals who will become future sources of medical costs, particularly patients with immobility and lack of access to care.

When deploying population health-management technologies to reduce unnecessary medical costs, hospitals and physicians in ACO arrangements should consider employing specialized staff trained in outpatient or post-discharge consumer education rather than repurposing existing facility-based clinical staff. For example, an ICU nurse placing follow-up calls to discharged patients is not the best clinician to provide support for the patient suffering from diabetes and related compliance with proper diet and medicine. Providers will need to deploy staff specifically trained in population health management, supported by the necessary technology to assure appropriate member identification, engagement, measurement and impacts.

Network management: Fueling transparency for informed decision making
A strong relationship between physicians and patients is crucial to changing patient behavior. In models of accountable care, hospitals and physicians will assume the role of ensuring that patients choose and access the best source of care for each clinical need. As patients begin to function as consumers in the healthcare industry, becoming accountable for their care, they will need transparency tools for the information necessary to make good decisions. Hospitals and physicians in at-risk arrangements will also have a stake in providing the network management tools traditionally deployed by payers to assist patients in selecting the appropriate physician for their situation.

Patients covered in an ACO arrangement accessing care at the wrong place and time may prove an important source of inefficiency for hospitals. Network management technologies empower patients to research the best care provider for their health condition. With contemporary transparency tools, providers can positively influence patients’ decisions and increase patient involvement. Furthermore, transparency assures that both patients and providers in ACO arrangements benefit from the best care at the optimal time, and in the optimal clinical setting, and open the door for better communication across the care continuum. With the right technologies, staff and programs in place, hospitals, physicians and health systems can be empowered to influence all membership for which they are accountable to make optimal health decisions. In models of accountable care, providers are positioned to take on both financial risk and reward, motivating and rewarding them to take an active role in patient lifestyles and behaviors, including compliance with appropriate preventive and chronic disease follow up.

About the author
Miles Snowden is chief medical officer of OptumHealth. For more on OptumHealth, click here.


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