At Infosys, our focus on Healthcare is aimed at radical progress in affordability, wellness, and patient-centricity. We believe technology is a catalyst for game-changing healthcare solutions. In this blog, we discuss challenges, ideas, innovations, and solutions for the healthcare economy.

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August 25, 2011

Disease Management- DMOs way forward

Disease management is an approach to manage chronic illnesses through prevention, patient centricity, evidence based practice guidelines and outcome based with an emphasis to improving the overall health. Traditionally heart diseases, diabetes, pulmonary diseases and asthma are considered in this.

Since 10% of the patients account for over 70% of the overall healthcare costs, focusing on this population can help in significantly reducing the overall costs of healthcare as well.

5 years ago, over 75% of the disease management was outsourced to DMOs (Disease Management Organizations)  since it was considered a specialty. Now, most of the payers have brought some form of disease management in-house and less than 40% of the disease management efforts are outsourced.  DMOs are now seeing opportunities mostly in wellness instead of disease management.

DMOs charge fees based on number of members they cater to. If some of their services can be tied to Health outcomes, they could emerge as leaders in Disease management. Any thoughts?

August 18, 2011

Promoting accountability in ACO - A few insights (Part 2)

In the previous blog, we have introduced the two key concepts that are going to influence the success of an Accountable Care Organization (ACO):

• Establishing and adhering to a central Vision

• Establishing a standard clinical process and benchmark

In the previous blog, we had started the discussion on the first topic i.e. Adherence to a central vision, and here we will extend our discussion further on the same.  It has been observed that one of the primary reasons of higher cost of healthcare in the U.S. is the existence of the fragmented healthcare delivery organizations. Collaboration among the constituents has been suggested as one of the solutions if one wants to succeed as an ACO. But is it enough to put a right setup of people, process, technology and infrastructure? Most importantly, the ACO organization has to plan for an effective change management so that the gap between the current and future states in all the areas of healthcare continuum can be bridged.

The vision will drive the change management process as it sets out the final objective very clearly before all the constituents.  Each of them needs to evaluate to what extent its current processes and practices will take them towards the vision. Then in such cases what are the key focus areas that are to be assessed? The assessment will not exclude any of the stakeholders (for example, providers need to assess the impact to the members towards improving provider-member collaboration). One important area that needs to be kept in mind during assessment phase is establishing mechanism to build trust among the stakeholders in the proposed state and minimize the silos currently existing.  Providers do not trust the clinical data maintained by the members which is one of the main reasons behind the alienation of PHR (personal health record) data. All of us know Google is withdrawing its Google Health service due to lack of membership.

Requirements for regulatory compliance from CMS and other federal and state regulatory authorities will play an important role in the assessment phase. One of the current rules of the Medicare Shared Savings Programs (MSSP) mandates that at least 50% of the participating providers in an ACO must be meaningful users of EHR. There are rules on adoption of outcome based payment model in ACO. The extent of change required to change the prevalent fee-for-service reimbursement model in the Non-ACO model to adopt the outcome based payment model will be another critical inputs to the assessment. Another important aspect will be how to establish collaboration between providers and the members especially in terms of establishing a centralized accessible patient health records without maintaining separate systems for personal health records. These are a few scenarios mentioned here for illustration purpose and there other rules as well.

All these factors need to be accounted for in the assessment leading to effective change management strategies. For example, there is a central clinical strategy and IT strategy. The central assessment will decide whether a new process will be established or already established systems/processes will be leveraged and integrated to form the central processes. Each individual constituent need not spend time and material to establish their own framework rather they can use a centrally established infrastructure/framework. This way, the cost will go down significantly and also will ensure right collaboration.

The important thing here is each of the constituent organizations needs to bridge the gap between the current state and future state in an ACO organization. This governance responsibility can be owned by a central group covering all the stakeholders. The central governance team has a very critical role to play in managing various processes and doing conflict resolution.

IT can be leveraged here to a great extent in spreading the awareness. Since the main purpose is to improve quality of care and reduce cost, the providers need to know and understand "How" and "What" part of the whole initiative. Each individual constituents need to be involved in forming the strategy which will help get a buy in from all. The required mechanisms need to be in place for collecting and analyzing these data and presenting before the central governance team. A lot of efforts need to be spent in this direction because it is very important that everyone is aligned with the vision. The important concerns need to be resolved before taking off as an ACO organization.

August 4, 2011

ICD-10: What goes along with Financial Neutrality?

With the transition to ICD-10, payers will certainly leverage the added granularity to improve their existing policies, adjudication rules and benefit categories. So, now certain services will be covered and paid, while others will no longer be covered and might be pended or denied if the claim is filed. These decisions will be crucial during the transition from ICD-9 to ICD-10 because any loss or misinterpretation of information about clinical issues will invariably distort the ability to ensure neutrality with respect to claims payouts. We also know that payers do leverage certain software (DCG/MEG/DxCG/CRGs) to predict their member expenditures or prospective provider reimbursements for members with multiple, combination or complicated conditions. These prediction software systems (which are all in ICD-9 as of today) will be migrated to ICD-10. Lack of clinical coherence in their transformation process will invariably alter the coverage group and risk pool definition, along with the member risk profiling and stratification statistics - all of which will ultimately impact the bigger goal of achieving financial neutrality at an enterprise level.

Please read the complete article in my blog post at ICD10HUb.com.

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