• November 2008 FEATURE ARTICLES •
Thought Leaders
Collaborative Accountability
By Emad Rizk, M.D.
As the cost of healthcare continues on its
upward trajectory, the calls for accountability grow louder.
Consumers demand that care be affordable, accessible and of high
quality. Providers believe that the system must provide them
with fair reimbursement that is transparent and rewards good
performance and quality of care. Payers want providers to
practice the type of medicine that keeps patients healthy and
meets medical necessity and appropriateness of care. So, who is
ultimately responsible for the patient’s health? On whose
shoulders does the effectiveness of the healthcare system rest?
A Moving Target
Consumer-directed healthcare — whereby
patients take on a greater portion of their medical costs as a
way to drive smarter healthcare decision-making — puts the
consumer at the center of the accountability equation.
Pay-for-performance puts accountability squarely on the
provider. Meanwhile, payers must bear a good deal of the burden
of responsibility for patient health because they possess the
best access of all healthcare constituents to the entire scope
of data within the system.
Payers also have the hard-won experience of
using that data to drive outcomes. All of these movements, at
least in their current incarnations, put an unfair and
unrealistic burden on their intended targets without providing
the appropriate tools, information and infrastructure to make
these movements successful.
Collaborative Accountability
What’s needed is a model by which the
different stakeholders agree on their respective
responsibilities. Because of each group’s unique position in the
healthcare system, and singular strengths, it only makes sense
that accountability should be a collective endeavor.
In this model, patient accountability means
being a good steward of one’s own health. The first step
involves filling out an employer-provided health risk assessment
(HRA) and having a regular physical, then using that information
to determine a plan of action. That plan of action must be
informed by various payer-provided tools, including educational
information about medical conditions, disease-specific classes,
home-monitoring devices and Web-based tools that help patients
track their medical progress.
For example, if you are overweight or a
smoker, your health plan will pay for weight management classes
or smoking cessation classes, and reward success by lowering
your premium. Similarly, if you are diabetic, have congestive
heart failure or are hypertensive, you will be offered help with
managing your conditions. And again, your premium level is tied
to your actions, so accountability means taking control of your
health, with the appropriate incentives attached.
This is a cost-neutral proposition, as
incentives would be offset by increased premiums for unhealthy
choices. The wisest health choices reap even larger long-term
rewards in the form of better health outcomes and reduced
medical costs through improved self-management.
Employers play an important role in this
model, by not only providing tools like HRAs, but also by
monitoring the health status of their entire employee population
and being alert to health trends that may require intervention;
for example, offering an onsite smoking cessation program.
Providers — both physicians and hospitals —
should share the responsibility for health outcomes; and they
must do this not only by delivering superb episodic care, but
also by helping patients modify unhealthy behaviors, practicing
preventive medicine and expertly managing chronic disease.
Chronic illnesses, according to the
Dartmouth Atlas, cause seven out of 10 American deaths and
account for 75 percent of U.S. healthcare expenditures. Until we
do a better job of caring for patients with chronic conditions,
morbidity and mortality rates will continue to belie the fact
that we are one of the most resource-rich, medically
sophisticated healthcare systems in the world.
Here’s where the payers takes on a new role.
As the repository of most of healthcare’s data — from clinical
content to claims data, from laboratory values to benefit and
eligibility information — health plans are the stakeholders who
can most easily provide the infrastructure and technology to
bring together financial and clinical information at the point
of care. This can assist providers in ascertaining not only the
short-term medical needs of their patients, but the long-term,
big picture needs as well. Furthermore, because few providers
can afford this type of technology, it’s incumbent upon the
payer to play a significant role in the funding.
These payer-provided tools would help care
givers manage their patients across the continuum of care and
include electronic health records; telephonic services to triage
patients and alert providers for follow ups and, hopefully,
avoid unnecessary emergency department visits; and disease
management nurses to counsel chronically ill patients. In many
ways, this is a return to the old model of the family physician
— a trusted confidante who spent enough time with patients to
uncover issues that may not have been immediately apparent, and
considered counseling and education part of doctoring.
These days, physicians are trained to treat
patients episodically, and our reimbursement system reflects
this, so this new approach will represent a huge paradigm shift
for many providers. Benefit designs and reimbursement systems
are going to have to reflect this change, by clearly outlining
physicians’ responsibilities in this new model and adequately
compensating them.
Payment and Execution
Where will the money come from to support
this new paradigm? With a health system as huge and complex as
ours, and total healthcare spending in 2007 at an estimated
$2.26 trillion ("National Health Expenditures, Forecast summary
and selected tables," Office of the Actuary in the Centers for
Medicare & Medicaid Services, 2008, accessed March 20, 2008),
there are many promising areas for savings. Eliminating fraud
and abuse, which currently costs the system about $90 billion a
year, is one promising area. Another would be managing molecular
diagnostic testing; an exploding area that currently represents
$4 billion in medical costs per anum. Additionally, once
provider/payers better manage their patients, chronic illnesses
will be better controlled, saving money on treatment and
hospitalization.
However, even with available funds, we face
the challenge of securing buy-in from the various constituents.
We must focus on changing payer/provider behavior and building
trust between these groups; and consumers should be at the table
too. To accomplish this we will also need boundaries and
measurable outcomes. As healthcare is delivered locally, an
appropriate plan of action would be to define and execute a
demonstration project with a specific population, such as
Medicaid recipients; HIV or end-stage renal failure patients, to
build up processes and technology. This endeavor could become a
proof point from which to build trust and base larger future
initiatives.
Stakeholders in the healthcare system need to
collaborate more effectively; focus on administrative, economic
and clinical outcomes, and use technology to facilitate all of
this. Accountability in healthcare has been a moving target for
too long, as the burden has shifted across stakeholders. It’s
time to move beyond that unstable model to one where each
constituency draws on its strengths to create a model of
collaborative accountability that benefits patients as well as
the entire healthcare system.
Emad Rizk, M.D., is president of McKesson Health Solutions. Contact him at
emad.rizk@mckesson.com.
