The Futurist

Joe Flower on shift­ing to riskbased payment

Modern Healthcare - - CONTENTS - Joe Flower is a health­care futurist, speaker and au­thor of How to Get What We Pay For: A Hand­book for Health­care Rev­o­lu­tion­ar­ies. BY JOE FLOWER

The changes will be driven by the new eco­nom­ics of health­care em­bed­ded in the “vol­ume to value” move­ment, based as it is on “provider-spon­sored risk,” the ba­sic, ob­vi­ous and yet star­tlingly opaque logic that you de­liver what you are paid to de­liver—so if you are paid dif­fer­ently you will de­liver dif­fer­ently. If you are paid fee-for-ser­vice, you will de­liver it in ways that de­rive the max­i­mum of fees for the max­i­mum of ser­vices. If you are paid based on be­ing at risk in one way or an­other for the health of the patient, you will in­vent, im­ple­ment and evolve the most ef­fi­cient ways to de­liver the health.

We are right at the be­gin­ning of this change. Let’s ex­am­ine it.

What way of dis­tribut­ing care is best for health? Care should be eas­ily and widely avail­able, es­pe­cially in an emer­gency or cri­sis. When we need it, we should have easy ac­cess to the best that medicine has to of­fer.

The rest of the time, care should be seam­lessly wo­ven into our lives, ex­pertly help­ing us pre­vent or man­age dis­ease and fine-tune our own body sys­tems. And it should not bank­rupt us. It should never force us to choose be­tween buy­ing our can­cer drugs and pay­ing the rent or buy­ing food for our chil­dren.

The fee-for-ser­vice sys­tem en­cour­ages, in­deed de­mands, that health­care or­ga­ni­za­tions pro­vide care in some kind of op­po­site-land con­struct, mak­ing it scarce, hard to ac­cess both phys­i­cally and fi­nan­cially, based en­tirely on episodic care de­liv­ered only face-to-face with the in­di­vid­ual clin­i­cian in the clin­i­cian’s pre­ferred place of busi­ness.

Risk drives change

Now providers are tak­ing on risk in a hun­dred dif­fer­ent ways, from bun­dled pay­ments to ac­count­able care or­ga­ni­za­tions to risk-based em­ployer and Med­i­caid con­tracts. All of these en­cour­age and in some ways de­mand that providers flip the sce­nario, bring­ing as much care as pos­si­ble closer to the patient, with more seam­less help as con­stant as is help­ful, with greater sup­port for those who need it most and at lower cost not only to the patient but to the payer.

This move­ment to provider-spon­sored risk is just be­gin­ning. The end point will likely be that most peo­ple in most sit­u­a­tions will be cov­ered by com­pre­hen­sive cap­i­tated in­sur­ance, with their med­i­cal needs pro­vided by large re­gional net­works. These or­ga­ni­za­tions will of­fer seam­less care, in­clud­ing pre­ven­tive ser­vices, pri­mary care via group prac­tices, re­tail and ur­gent set­tings, as well as chronic and acute man­age­ment. They will also pro­vide post-acute op­tions and the full ar­ray of spe­cial­ized ser­vices. De­spite the com­pre­hen­sive­ness of these largely cap­i­tated re­gional sys­tems, the de­mand for ef­fi­cient, lower-cost qual­ity care will mean they also must have the flex­i­bil­ity to of­fer their pa­tients con­tracted ser­vices else­where for spe­cific types of ma­jor care, such as can­cer care, joint re­place­ment and car­dio­vas­cu­lar ser­vices.

Ecol­ogy of touch points

Health­care dis­tri­bu­tion will change on every axis: time, place, fre­quency and man­ner. Care at the ba­sic and chronic level will be pro­vided through a wide va­ri­ety of touch points, in­clud­ing pri­mary med­i­cal homes; on-site clin­ics at work, school and el­der-liv­ing fa­cil­i­ties; pop-up clin­ics at churches; re­tail care in big-box stores, ur­gent care at the mall; house calls for “su­per users” and im­me­di­ate dis­charges; and a web of sen­sors for those who need it, in­clud­ing an “in­ter­net of things” in the home en­vi­ron­ment—the toi­let, the mir­ror, the tele­vi­sion; health watches, con­tact lenses, smart patches and im­plants—all tuned not just to pro­vide in­di­vid­u­als with their own in­for­ma­tion, but to tie them into their fam­ily care­givers and the clin­i­cians with whom they have a trusted re­la­tion­ship: their doc­tor or nurse prac­ti­tioner as well as the sys­tem’s elec­tronic health records.

These con­stant dig­i­tal con­nec­tions can sup­port the trusted per­sonal re­la­tion­ship with the clin­i­cian and the sys­tem. They can­not ef­fec­tively ini­ti­ate or re­place that con­nec­tion. Au­toma­tion and ar­ti­fi­cial in­tel­li­gence can be pow­er­ful in build­ing ef­fec­tive and ef­fi­cient health­care, but they can never sub­sti­tute for the core re­la­tion­ship with a clin­i­cian.

The shape of these changes will be driven by mul­ti­ple pa­ram­e­ters:

The broad drive for prac­ti­cal, ef­fec­tive health man­age­ment for whole pop­u­la­tions.

The nar­row need to tar­get ex­tra help for the “su­per users” with mul­ti­ple chronic prob­lems and fre­quent emer­gency de­part­ment vis­its, as well as spe­cific high-use groups such as moth­ers with young chil­dren.

The deep eco­nomic value in both cases of mov­ing closer to the cus­tomer and ear­lier in the dis­ease cy­cle, as well as strongly con­nect­ing not only with the patient but with the patient’s home care­giver, child, par­ent, spouse or close friend.

The de­vel­op­ment of rapid, ef­fec­tive, con­stant tech­nolo­gies for con­nect­ing the cus­tomer to the sys­tem over chronic-care cy­cles

The ef­fec­tive need to build all of these along lines of trusted per­son-to-per­son con­nec­tions.

Trust—the en­gine of ef­fi­ciency

The last of these is crit­i­cal. In all this change, the least un­der­stood en­gine of ef­fi­ciency and ef­fec­tive­ness is trust. Par­tic­u­larly in pop­u­la­tion health man­age­ment, preven­tion and pri­mary care, the trust and co­op­er­a­tion from the patient and the patient’s fam­ily is an es­sen­tial el­e­ment. The busi­ness model doesn’t work with­out it.

As we are build­ing out these new net­works and touch points, many strate­gists are madly reach­ing for tac­tics that ac­tu­ally re­duce the per­son-to-per­son hu­man el­e­ment. It doesn’t work. The ex­pe­ri­ence of mul­ti­ple pi­lot pro­grams and re­peated stud­ies show that preven­tion or pop­u­la­tion health man­age­ment by robo­call, or call cen­ters with scripts, or nags via text mes­sage, sim­ply does not work. Peo­ple do not change their lives and habits based on a mes­sage or call from a stranger.

As we move for­ward un­der the goad of risk-based payment sys­tems, sys­tems will quickly dis­cover what does work. Build­ing and strength­en­ing trusted per­sonto-per­son re­la­tion­ships will be­come a foun­da­tional part of the new shape of health­care.

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