Bet­ter care at lower costs

Pan­elists dis­cuss the chal­lenges of build­ing a broader con­tin­uum of care

Modern Healthcare - - EDITORIAL WEBINAR -

Edi­tor’s note: Fol­low­ing is an edited ex­cerpt of the tran­script for Mod­ern Health­care’s May 6 edi­to­rial we­bi­nar, “Build­ing the con­tin­uum of care: Now that you own it, how best to weave it into your op­er­a­tion.” The pan­elists were David Grabowski, pro­fes­sor of health pol­icy at Har­vard Univer­sity; Michael Rowan, ex­ec­u­tive vice pres­i­dent and chief op­er­at­ing of­fi­cer at Catholic Health Ini­tia­tives; and Linda Young, pres­i­dent of As­cen­sion Health’s Rev­er­ence Home Health & Hospice. Mod­ern Health­care re­porter Me­lanie Evans mod­er­ated a dis­cus­sion ex­plor­ing the chal­lenges providers face as they reach into a broader con­tin­uum of care with the goal of de­liv­er­ing bet­ter care at lower costs.

Me­lanie Evans: What’s at stake as providers and pay­ers are try­ing to de­velop an ap­pro­pri­ate risk ad­just­ment model, what are some of the lessons we learned from the last time around, and what are the cur­rent chal­lenges in de­vel­op­ing a pay­ment that ad­e­quately com­pen­sates for the com­plex­ity of var­i­ous pa­tients? David Grabowski:

Even if we just think about hos­pi­tal pay­ment, we used to have cost-based pay­ment. We ob­vi­ously moved to a prospec­tive pay­ment sys­tem based on the di­ag­no­sis-re­lated groups, or DRGs, in the early ’80s, and that was a hope that we can be­gin to curb some of the high spend­ing and high uti­liza­tion in the hos­pi­tal sec­tor.

I think we’ve seen a big de­crease in length of stay, but what that caused was a lot of shift­ing across set­tings, and the use of post-acute care mush­roomed the read­mis­sion prob­lem.

So now as we be­gin to think about global pay­ment, we’re back to sort of think­ing about, how do we ad­e­quately ad­just risk? I’ve yet to meet the provider who doesn’t think they’re car­ing for a sicker set of pa­tients. And so risk ad­just­ment is in­cred­i­bly cen­tral to any of this.

I think the real chal­lenge here is that, one, we’re work­ing out­side the data. We can be­gin to look at, for ex­am­ple in bun­dled pay­ment, what does 30-day uti­liza­tion look like fol­low­ing dis­charge? But try­ing to get the ap­pro­pri­ate rates for the hos­pi­tal sys­tem, for the physi­cians in the bun­dle, and then the post-acute providers as well, is re­ally chal­leng­ing. And then think­ing about how that rate gets di­vided up.

We can all agree that uti­liza­tion is too high un­der the cur­rent sys­tem. But then think­ing about how we ac­tu­ally ac­count for this very dif­fer­ent mix of pa­tients across providers is re­ally chal­leng­ing.

Now imag­ine that you’re try­ing to risk-ad­just an en­tire set of health­care ser­vices. Imag­ine it’s a du­ally el­i­gi­ble in­di­vid­ual and you’re try­ing to risk ad­just all their Medi­care and all their Med­i­caid.

We can all agree there’s a lot of in­ap­pro­pri­ate uti­liza­tion, some waste that we could elim­i­nate in the sys­tem, but try­ing to fig­ure out what’s the ap­pro­pri­ate pay­ment rate? I think given the num­ber of ser­vices that are in the bun­dle or in the cap­i­tated rate with the com­plex­ity of the pa­tients makes this in­cred­i­bly chal­leng­ing.

Think about even our cur­rent pay­ment sys­tems. If you take home health pay­ment, we have all the out­lier pay­ments and com­plex­i­ties and the risk. All of that is so com­plex. That’s just for home health­care alone. Now think about putting home health­care in this bun­dle or in a cap­i­tated rate. It’s that much more com­plex for a very sick pop­u­la­tion mix. Evans: Michael, how has Catholic Health Ini­tia­tives tack­led the ques­tion of risk ad­just­ment as you di­ver­sify your ser­vices?

Michael Rowan: In many ways, when we think about this whole idea of ap­pro­pri­ate risk ad­just­ment and pay­ment, it’s re­ally a scary propo­si­tion be­cause this is a new and dif­fer­ent kind of work, and the re­al­ity is, if you get it wrong, disas­ter looms out there. And so as an or­ga­ni­za­tion, we’re try­ing to go into the whole process by do­ing a se­ries of pi­lots out there with smaller pop­u­la­tions so that we can kind of test the wa­ters. And I note we’re also try­ing to be­gin to think about how we learn to man­age the care of the pop­u­la­tion we’re al­ready at risk for, and that is our own em­ploy­ees.

It’s about un­der­stand­ing a pop­u­la­tion and its uti­liza­tion pat­terns, and it’s then about un­der­stand­ing how you can im­pact those uti­liza­tion pat­terns and what’s the cost of im­pact­ing those uti­liza­tion pat­terns. For us, it’s meant that we’ve had to im­port new skills into the or­ga­ni­za­tion—epi­demi­ol­ogy, ac­tu­ar­ial science—and we started to build in­fra­struc­ture specif­i­cally around busi­ness in­tel­li­gence data man­age­ment so that we can in­tel­li­gently sup­port risk in in­sur­ance ven­tures.

You look back at the ’80s and ’90s with the whole HMO thing, and their reaction to get­ting it not quite right was to with­hold care. And as we move for­ward, that’s not what we want to do.

We want to be very clearly fo­cused on, how do we pre­vent the need for ex­pen­sive care so that we op­er­ate within what­ever pa­ram­e­ters of risk there are out there, and how do we do that by cre­at­ing well­ness in both in­di­vid­ual pa­tients and across the de­fined pop­u­la­tion so again they don’t need ex­pen­sive care? This is a ma­jor un­der­tak­ing for any or­ga­ni­za­tion and cer­tainly for any or­ga­ni­za­tion that’s his­tor­i­cally been an

acute-care, hos­pi­tal-based kind of or­ga­ni­za­tion. Evans: Can you de­scribe the risk tools that you may have de­vel­oped to strat­ify pa­tients as they’re ad­mit­ted in the post-acute set­ting so that they get the ap­pro­pri­ate in­ter­ven­tion or care that they need? Rowan: In many ways, we’re just start­ing that process, and prob­a­bly we see it right now in our kind of prim­i­tive way be­gin­ning to rely on two things:

No. 1 again is data, and that is we’re build­ing our own in­ter­nal data ex­change, our en­ter­prise in­for­ma­tion sys­tem, fo­cused on a busi­ness in­tel­li­gence func­tion where we can take in­for­ma­tion and make in­tel­li­gent de­ci­sions and pre­dic­tive be­hav­ior about spe­cific pop­u­la­tions.

And that’s a par­tic­u­lar chal­lenge for us as an or­ga­ni­za­tion be­cause, his­tor­i­cally, we didn’t even have our own data. We started off buy­ing our own in­for­ma­tion about our pa­tients, of­ten from in­sur­ance com­pa­nies and the like, but now we’re start­ing to ac­cu­mu­late that data. So that’s one piece of it. And it lit­er­ally is a busi­ness in­tel­li­gence func­tion within CHI.

The sec­ond piece is build­ing out our care model, and in our care model we’re try­ing to de­velop, if you will, two things. One, a chronic-dis­ease-man­age­ment ca­pa­bil­ity— that is, we know the op­ti­mal way to take care of any pop­u­la­tion of di­a­bet­ics. And then sec­on­dar­ily, what we call an ex­ten­sivist care model. We’re be­gin­ning to think about how you man­age those tran­si­tions of a pa­tient dur­ing any par­tic­u­lar ill­ness, be it acute or chronic, from what’s hap­pen­ing pre-acute, to in­pa­tient, to post-acute, to home care, to chronic dis­ease man­age­ment. And it’s re­ally those hand­offs, it’s that co­or­di­na­tion. Linda Young: As I think about Rev­er­ence and the work that we’re do­ing in home health, I go back to Mike’s com­ments that he just shared re­lated to chronic-dis­ease man­age­ment, the ca­pa­bil­ity re­lated to that as well as man­ag­ing the tran­si­tions.

I think it’s just crit­i­cal that home health is at the ta­ble dur­ing th­ese dis­cus­sions be­cause as we think about the pa­tient move­ment from one en­tity to the next, it re­ally is that hand­off from one provider to the next that makes a huge dif­fer­ence in the pa­tient’s out­come.

Part of the work that we need to cont-inue to fo­cus on is re­lated to the IT sys­tem and as­sur­ing that as we build our health sys­tems and think about each of the en­ti­ties within a sys­tem—tak­ing care of that pa­tient from birth through the end of life—we re­ally do need to have health sys­tems that talk with each other so that hand­off can be trans­par­ent and the in­for­ma­tion that each provider or level of care needs is avail­able at the time that the new level of care is be­ing de­liv­ered. So as it re­lates to the risk ad­just­ments and eval­u­at­ing out­comes based on a pa­tient’s risk, I think it’s work that is absolutely on­go­ing as we speak and crit­i­cal to the suc­cess of our man­age­ment of the pa­tient’s care. Grabowski: There are ac­tu­ally now com­pa­nies that are work­ing with a lot of th­ese sys­tems that are ba­si­cally man­ag­ing or even tak­ing on the risk of their post-acute pop­u­la­tion and us­ing a big data­base to help sort of as­sign, or help to as­sign, pa­tients to par­tic­u­lar posta­cute set­tings, whether the in­di­vid­ual needs skilled-nurs­ing fa­cil­ity care, home health­care, and then how much care and kind of match­ing this in­di­vid­ual to a whole data­base of in­di­vid­u­als with sim­i­lar risk char­ac­ter­is­tics.

And, ob­vi­ously, we can’t ac­count for all the dif­fer­ent risks, and it’s more than just health that’s go­ing to im­pact your need and level of post-acute care. There’s fam­ily. There are all sorts of other un­ob­serv­ables, if you will, that are at play here. But there is this sort of in­dus­try com­ing up that is ac­tu­ally even above the provider level to think about sys­tem-level man­age­ment of post-acute care. Evans: Are there ways that CHI has sought to sys­tem­i­cally in­cor­po­rate some over­sight so that you can main­tain stan­dards, be it qual­ity or cus­tomer ser­vice? Rowan: I think a lot of it comes down to your ba­sic thought process on work­ing with con­trac­tors, and that is the de­vel­op­ment of ser­vice-level agree­ments.

Each time we con­tract with some­one who par­tic­i­pates with us, you know, I could say in de­vel­op­ing or de­liv­er­ing post-acute ser­vice, but the same thing could ap­ply to de­vel­op­ing IT sys­tems. We try to build into the con­trac­tual agree­ment, ser­vice level agree­ments, which say th­ese are the met­rics that you have to op­er­ate un­der if you are con­sid­ered to have ful­filled your end of the con­tract.

Now, that sounds pretty good and pretty easy, but the real chal­lenge—es­pe­cially as we move into post-acute care and build­ing out the con­tin­uum—is what should the stan­dards and bench­marks be, be­cause some­times they don’t ex­ist out there. If we’re in­volv­ing our­selves all the way to the pop­u­la­tion health man­age­ment, there’s also this whole chal­lenge of pre-acute care, if you will. That is, how do you keep peo­ple out of the acute side to be­gin with? And that’s an area we even know less about to set stan­dards, bench­marks and ex­pec­ta­tions than on the post-acute care side. Evans: Linda, I’ll ask you as well. Are there ways that you have tried to ad­dress main­tain­ing stan­dards as you have both con­sol­i­dated and ex­panded? Young: One of our cor­po­rate de­part­ments is a qual­ity depart­ment, and the re­spon­si­bil­ity for those folks is to over­see the qual­ity op­er­a­tions and out­comes for all of our sites. We also see that that’s a very lo­cal func­tion, and so we have lo­cal qual­ity as­so­ciates who work very closely with the cor­po­rate depart­ment, so that way we can re­ally make sure that the out­comes that we are achiev­ing with the care that we’re pro­vid­ing are meet­ing the stan­dards that we want as we con­tinue to grow and ex­pand across the state.

Evans

Grabowski

Young

Rowan

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