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What a difference a year makes! I am amazed how mindsets are changing in an industry that typically takes its sweet time to make any changes of significance.
In a sense, the whole debate around healthcare reform — both before and after it was enacted — shocked those who were not happy with the proposed models into starting their own initiatives around new models of care. We have entered a new era of collaborative care and provider transformation and, whether you believe in state-sponsored health insurance exchanges and ACO’s or not, one fact holds true: the lines between payer and provider are becoming blurred. Take the recent controlling interest that Pittsburgh insurer Highmark Inc. took in West Penn Allegheny Health System as an example. Hospitals, which are the core of this new wave of accountable, integrated care, are moving to models where they will take on more risk, and they are in dire need of new expertise and tools to help them manage populations rather than care episodes. This is something that payers have done for over 50 years, and they are now jumping in to help hospitals get there.
This week’s guest post comes from Martin Brown, M.D., FACEP, chairman of the Department of Emergency Medicine at Inova Alexandria Hospital in Alexandria, Va.. A key player in MEDS-ED Link, a grant funded project recently instituted by the Northern Virginia Regional Health Information Organization (NoVaRHIO), Dr. Brown discusses the impact of health information technology on patients in his facility.
We’re all aware that the evolution of healthcare technology is ultimately driven by a desire and need to improve patient care and operational efficiencies. However, many hospitals and clinicians today feel like they’re swimming in a sea of regulations, deadlines, implementations and go-lives. The plus side is that more and more frequently, we’re able to derive some improvements, motivation and gratification from the instances where access and sharing of clinical data across a healthcare community clearly makes an immediate difference in a patient’s treatment.
This week’s post comes from John Nackel, Ph.D., Chief 
Executive Officer at OptumInsight Consulting and Executive Vice President, OptumInsight (previously known as Ingenix). With more than 30 years of experience advising health care organizations, entrepreneurs and emerging businesses, John discusses his vision for Accountable Care Organizations.
The proposed CMS regulations on Accountable Care Organizations (ACOs) took the first step in promoting discussions about lowering costs, but how to align these costs between each healthcare stakeholder is still an issue and obstacle, leaving most of us to wonder — how will this all actually work? Confusion around how to develop the legal and financial framework that is an ACO, coupled with the complexity of aligning each constituency and enabling the model to continue to work effectively long-term — which we define as a Sustainable Health Community — may be driven by the provider. For some, this new model will mean huge opportunity and for others, significant risk.
This week’s guest post comes from Justin Chang, M.D., chief of emergency services, Kaiser Permanente, Colorado, and medical director, Exempla St. Joseph Hospital Emergency Department. A proponent of collaboration and enhanced coordination of care, Dr. Chang makes the case for a new model of healthcare delivery as defined March 31 by the Centers for Medicare & Medicaid Services (CMS) in its proposed ruling on Accountable Care Organizations (ACOs).
I think we can all agree — physician, payer, provider, patient, etc. — that the ultimate goal of regulations and reform should be to improve the delivery of healthcare, lowering costs and ultimately, making patients healthier and more satisfied. Coupled with driving toward the results defined by CMS, this requires some fairly significant changes in how healthcare providers operate — changes which may rightfully make some providers uneasy. But what many of us may not realize is that hospitals, physicians and payers across the country are already becoming advocates for the types of changes ACOs will require, supporting a shift away from the fee-for-service and silo-type models, even before the regulations go into effect.
I commented several months ago about how the hurried healthcare reform bill became so imperfect that there was no way it would not add to already escalating costs. But in accordance with the rule of unintended consequences, all the debate around the bill, along with the fear that some of its most onerous provisions like large cuts in Medicare for hospitals, has spurned a tidal wave in thinking and planning about new models of care that will be more efficient. We now hear the words “accountable care organization,” or ACO, more often than you heard “web strategy” during the dot.com boom. ACO is a technical term originated by the Brookings think-tank and adopted by CMS to cover the rules around ACO eligibility and qualification. However, the term “Sustainable Health Communities” (SHC) is a more descriptive term with the obvious connotation that left to our present course, the current system is unsustainable, and the addition of “community” extends all the way into all the pre- and post-acute care entities.
Football season may be over for the year. But for payers, the idea that “as goes the quarterback so goes the team” has never resonated as loudly as it does now — and will in the future — in the new world of Sustainable Health Communities.
Historically, payers have had an important, yet somewhat fundamental role: to select and manage risk, to negotiate favorable provider contracts, ensure its network is comprehensive, design appropriate benefit plans, manage care and provide appropriate customer service. Now, as we enter the era of Sustainable Health Communities, payers take on a new and even more critical function as the enabler — the head coach of the team where the primary care physician (PCP) is the “quarterback” in the local health care delivery system.
This week, Bill Miller – OptumInsight 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.
