This week, Bill MillerOptumInsight EVP responsible for provider strategy and solutions – explains why Sustainable Health Communities are both possible and probable in the years ahead as guest blogger for Healthcare-Exchange.

The buzzword du jour in healthcare is “Accountable Care Organizations”, or ACOs.  The cynics among us might ask “Weren’t we calling these ‘medical homes’ just a few short months ago?”  Those with long memories in addition to that dose of cynicism hark back twenty years and say these are just capitated HMOs.

The term is hardly what’s most important as the healthcare system evolves in response to healthcare reform, ARRA meaningful use, spending cuts, increasing regulation and a myriad of other influences, many of which are beyond the control of the hospital community.  What matters is the outcome, the building and operation of what we at Ingenix refer to as Sustainable Health Communities.

Sustainable Health Communities need to evolve in order for hospitals to survive and thrive in an era, now upon us, that will change the way providers are paid, and enable true coordination of patient care across the modern health ecosystem. While some opponents cite the failure of the capitation model in the 1990s, many of the obstacles of that era no longer exist, and we’re now living in a world in which a connected, aligned and intelligent approach to healthcare is both possible and absolutely necessary.

Patients, physicians, providers, payers and pharma companies all recognize the critical need for a healthcare system that delivers better outcomes, controls costs and provides an improved patient experience. As a result, Sustainable Health Communities can become a reality, with all key parties now owning risks and rewards involved in their success:

  • Patients – Consumers today have the ability to influence more than 50 percent of unnecessary clinical costs. They now crave information and education about their own healthcare, but are often faced with confusion about treatments, procedures, medical bills and delays in treatment. They are ready for, and increasingly demanding, a coordinated care effort where they stay informed, connected and involved.
  • Physicians – Currently, one-third of a doctor’s time is spent recording and synthesizing information. They want technologies and integrated systems that help them with access to essential patient data, complex payer requirements and revenue control – so that they can focus on providing patients with the best possible care.
  • Providers (hospitals, clinics, physician practices, etc.) – Heightened financial and clinical performance pressures, regulatory changes, reimbursement challenges and maintaining clinician relationships in a dynamic environment make Sustainable Health Communities the only long-term alternative for providers. As providers partner, they can drive toward shared objectives around efficiency and quality.
  • Payers – Under a Sustainable Health Community model, payers will contribute to the nation’s efforts to reduce healthcare spending and arrest spiraling costs. By sharing risk and accountability with providers, they also share the interest in using data about communities and populations to improve quality and can offer a comprehensive approach to patient care.
  • Pharma – While they may fight it, drug developers can benefit from population analytics, early detection of diseases and improved pharmacy payment systems – not to mention data-driven program and performance measurement of certain therapies. Sustainable Health Communities will offer pharmas and biotechs the ability to improve R&D with better insight into a range of patient types, clinical trial recruitment and new market opportunities.

Sustainable Health Communities can succeed in 2011 and beyond because of these changes:

  • Interoperable technology that offers near real-time information at the point of care, streamlines administration, and manages compliance risks and costs;
  • Alignment in accountability for patient-centered care delivery and continuity of care;
  • Implementation of performance-based and evidence-based payment models; and
  • Personal responsibility for lifestyle choices and health management.

While the constituencies haven’t always worked together (or have been long-time antagonists), many of these ingredients are available today, and we know we’re on the right path to bringing them to market. With technology innovation, coupled with the motivation to bring all parties on board – each of which are critical to the modern healthcare ecosystem – I’m confident we’ll see successful Sustainable Health Communities throughout the U.S. in the near-term.

Bill Miller