Becker's Hospital Review

28 Executive Briefing: Payment Models and Reimbursement Proper screening of and managing the primary health needs of a patient population saves money by keeping chronic diseases in check and by helping patients avoid expensive hospital or emer- gency room visits. As one chief medical information officer noted, it's the difference between "population disease management" and true "population health management." You should identify a vendor that can support your system with the tools and knowl- edge necessary for complete reporting, tracking and benchmark- ing of your financial and clinical performance — including the full downstream consequences of every ordering decision made (or missed). This insight should be shared through medical-record ordering pages so that caregivers are always current, in the mo- ment of care, with the best referral choice — including what to order, where to order it and where to schedule it. 4. Predict who will develop issues A crucial step to succeeding with a mix of reimbursement is to use both claims and clinical data to stratify patients depending on their health needs and their likely utilization of services. That includes relatively simple analyses that identify patients in need of routine care such as physicals, mammograms, colonoscopies and other routine screenings. Identifying patients in need of care makes good business and clinical sense whether you are being compensated for managing a population or simply treating indi- vidual patients. The current market for population health management tools em- phasizes predictive analytics to identify patients who will devel- op issues and require higher spending. Purchasers looking for population health tools commonly confuse risk-adjustment (the normalizing of costs and outcomes based on the number and severity of co-morbid conditions) with predictive analytics. Pre- dictive analytics is an emerging field of big data, utilizing compli- cated algorithms and statistics. While promising, true predictive analytics is in its infancy, and on the whole, identifying the bulk of patients likely to generate higher costs is not complicated — they are usually the patients who have generated costs in the past. Finally, predictive analytics are useless unless patients can be engaged and influenced. A recent spot-test of athenahealth clients found that 85 percent of eligible Medicare beneficiaries had not complied with free wellness visits. This represents a missed opportunity for preventive care and revenue — a strik- ing example of across-the-board failure at even basic (healthy) patient engagement. 5. Identify early opportunities for utilization reductions Target reductions where there are clear opportunities for savings. Under new contracts, 30-day readmissions, the occurrence of "never events" in hospitals and the development of complications are increasingly uncompensated. Gaining control of and reducing these events is critical to reducing needless expenditures. It also makes sense to reduce durable medical equipment ex- pense by utilizing lower-cost suppliers. In situations where you must refer patients to out-of-network services, utilizing higher- quality, lower-cost providers is essential. 6. Support chronic care and disease management A three-step process can also help drive responsible, medically necessary volume. First, your system should ensure patients who are essentially healthy receive essential screening tests. Second, you should provide appropriate, high-quality, cost-effective care when patients fall ill. And third, you should improve the manage- ment of patients with chronic illness through better care coordina- tion and targeted care management. This final step is the most difficult. But health systems can use cost savings from steps 1 through 4 above to fund disease man- agement programs. The establishment of care-management or disease-management programs can be an expensive proposition, and the cost reductions obtained through these efforts frequent- ly take years to accrue. If disease management is part of your strategy, fund these initiatives through cost reductions from the steps above first. Once care management is implemented, it is essential to target patients with meaningful opportunities for cost reduction. For example, the vast majority of diabetic patients will not contribute to substantial costs, so diabetes programs should be targeted at patients who are heavy users of ED or hospital ser- vices. Conversely, substantial costly programs aimed at patients in the pre-terminal stages of chronic illness are rarely successful at reducing costs. With healthcare costs under scrutiny from purchasers, and the aging of the population, pressure is mounting in the U.S. to provide quality care while controlling costs. Having strong health IT is the backbone of providing the coordinated care that is essential to succeeding in healthcare's new reimbursement landscape. Health executives and administrators should seek an HIT partner that offers both technological and business- process support — in short, a partner willing to take on re- sponsibility for delivering real results from the six-step process listed above. The reward will be a partnership that brings more patients in need of services into the health system, that keeps the organization competitive and its revenue strong and that engages patients in order to deliver better, more comprehen- sive care. n athenahealth is a leading provider of cloud-based services for EHR, practice management and care coordination, named the Best in KLAS #1 Overall Software Vendor for 2013. With a cloud-based network of more than 50,000 providers, athenahealth helps caregivers thrive through change and stay focused on patient care. Learn more at athenahealth.com.

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