My suggestion is that the Health Plans allow such members to use the Retail clinics for preventive services, while the PCP takes charge of the chronically ill patients. This calls for an integration between the retail clinics and physician offices. EMR can be electronically transferred and shared between the Retail Clinics and the Physician offices. This will also keep the American Medical Association (AMA) happy because the minute clinics are no longer in battle with the Physicians but are in cahoots. Can this be a win-win-win-win situation for the Health Plans, Physicians, Patients and the Minute Clinics? Thoughts?

1. Transformation to orchestrated business models having a neat, higher degree of integration of value-adding processes and facilitated networks namely evidence based practice, closed loop medication, retail health, PCMH, ACO & etc.
2. Moving away from the status quo to open market innovation (e.g. mobility, digital hospital etc.) with integrated public health utilities (e.g. automated public health surveillance, focused primary care to facilitate preventive care in place of reactive care & etc.) and aiming for a larger focus to achieve the WHO's "Health for All".
3. Enabling true consumer empowerment with technology supporting them to get "only" what they need, e.g. Interfaced intelligent devices synced up with portals for self-diagnosis, decisions & social interactions- A trending shift from consumerism to prosumerism. Thus, enabling convenience, ensuring responsiveness and a better healthcare experience.
4. Redefining the existing care cost structure with a pulse of accountability and ownership- A paradigm shift from so called global to bundled to condition based reimbursement models.
5. Going GREEN, consolidation & virtualization of Healthcare IT infrastructure to reduce operational cost & adoption of cloud to respond the impending healthcare information explosion.
6. Adoption of pervasive computing to enable remote automated patient diagnosis, treatment & monitoring e.g. telecare, telesurgery, remote sensors that will ensure continuous capture and analysis of patients' physiological data.

Difficult though, but healthcare organizations need to disrupt themselves with a focused investment of energies, talent, and resources and start playing a more proactive role in orchestrating these emergence compared to the reactive posture they have taken in the past. The very fluidity of the current healthcare market will further make these aspects more promising and attainable. Just my 2 cents before I think to conclude- If we act from today and if we act together to remove the cobwebs of rhetoric (political and commercial) - the goal to make the current healthcare system fiscally sustainable is absolutely within reach.

Following are the key issues..

In the light of this, many leaders are looking at other organizations who are lagging behind and hoping that someone else in the organization is accountable for this.  While there is no indication of any extensions, some leaders are hoping against hopes.

My suggestion is that the Health Plans allow such members to use the Retail clinics for preventive services, while the PCP takes charge of the chronically ill patients. This calls for an integration between the retail clinics and physician offices. EMR can be electronically transferred and shared between the Retail Clinics and the Physician offices. This will also keep the American Medical Association (AMA) happy because the minute clinics are no longer in battle with the Physicians but are in cahoots. Can this be a win-win-win-win situation for the Health Plans, Physicians, Patients and the Minute Clinics? Thoughts?

By standardizing the clinical practices and referring to it as a standard practice during diagnosis and other clinical procedures will help establish a central repository of best practices at the ACO level. This will be a dynamic repository which needs to be constantly updated. The ACO needs to establish the performance parameters and goals (such as those mandated by CMS for an ACO) and create its own internal benchmark. The benchmark will help ACO assess its own standing vis-à-vis the industry benchmark and continuously improve upon it. The main purpose behind standardization is to reduce variation in care, primarily by the physicians in an ACO, which will be the key to any successful strategy for improving outcome and lowering costs.

The regulatory compliance requirements have influenced the need for a stronger collaboration among the stakeholders. With the advent of ICD 10 codes, there is a need for a standard way of interpretation, documentation (Clinical) and coding across the ACO. The doctors and coders need to be well trained on these aspects at the ACO level as it will impact the reimbursement. 

The bundled payment proposes to pay the provider organization for the entire episode of care instead of paying each of the individual providers for providing a part of the care. This will suit the ACO way of working as already it has the right coalition established. In such a case, ACO will need a central policy/guideline of its own which will help the providers decide on the services to be bundled and under which situation.

One critical aspect is the availability of an appropriate and accurate analytics tool for the physicians in ACO.  In the current world, with the establishment of EHR, physicians will get all data at the finger tip. But will it ensure the physicians draw the accurate conclusion out of the data? The physicians need to spend adequate time and do the adequate synthesis of data at the beginning of the diagnosis. In a setup like ACO, the required collaboration between different departments or care providers can be facilitated to achieve this objective. The accuracy of the data synthesis process will help remove the unnecessary services, procedures, medications which will ultimately improve outcome and reduce the cost. 

•The calculation of overall financial benefit to participants of an Acountable Care Organization (ACO), which is still cloudy & dicey in the industry 
•The risk and reward model by the CMS which has been framed relative to the total cost of care and defined patient outcomes
•In spite of the fee-for-service model with the potential bonus payments for meeting defined quality standards, clinical outcomes and targeted cost savings, will the providers be able to achieve enough savings that will offset their initial set up investments like expenditures on electronic health records, tracking, monitoring outcomes, analytics and reporting?
•What if CMS requires ACO providers to accept more of the downside risk and if that becomes true then how much additional risk will the provider be willing and able to take?
•If the same ACO is used for commercial insurance, will there be a new delivery and payment system with the commercial payers? Will that result to an unsavory pricing, reimbursement and market allocation agreements?
•Will the ACO model flare up the power struggle between physicians and hospitals? As, it can be envisaged that if physicians come to dominate, hospitals' patient census might decline and hit the bottom line (may be with little compensatory growth in outpatient services). On the other hand, if hospitals dominate ACOs, the physicians will be consigned to the position of employees and contractors making it difficult for independent physicians to regain their control over the population & income

However, these are just some of the possible provider's concerns to decide whether or not they want to be an ACO but on the flip side, the ACO concept is a promised huge chance for provider organization to improve their operations through an integrated system, set up quality improvement and potentially reduce the usage of some unnecessary tests and treatments. I also feel that, it's too early to decide on whether its worth to be an ACO, when there are still many unknown and uncultivated facts around the upcoming ACO directives.  Time is more for the providers to decide how to make the transition right and strategic for their organizations, whether their geography, local health care environment supports to set up such an infrastructure, what opportunities are there to build relationship with other community providers to work together, how firmly they can partner for bundled payments and coordinated care transitions.  Just because there can be some upfront concerns, doesn't really mean that it's not prudent for organizations to be a part of ACO. It is obvious that there are definite ways in this care model where pay-off will certainly come. Providers need to look into organizations that are working today on a so-called ACO concept and analyze their experiences to enrich knowledge. So, it is the time for exploration and complete due diligence before really deciding to pursue or disregard this initiative...just my 2 cents.

Read the complete post at my blog space in Health Data Management.

The link below:

http://www.healthdatamanagement.com/blogs/health_care_technology_news-43121-1.html

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?

Starting in 2014, the state health benefit exchanges are required to setup a new marketplace where insurance can be bought the 'Travelocity' style. The health benefit exchange for small employers, un/under insured population will have a platform to view comparable and obtain clear information on benefits and costs of insurance plans.

Building the health insurance exchanges keeping these three different dimensions and mind sets is a tricky situation. Below are a few thoughts on how a site must be built to meet most of the needs of the three categories of audience.

1.Pleasing to view - The site has to be uncluttered. This is the universal requirement for all websites and the most important aspect. The user must be able to find what they are looking for very easily. The display, choice of images, colors, and font size of text form an essential characteristic for a visually pleasing website.
2.Inclusive:
 a.Classify information to be captured from the member as 'must have' and 'nice to have'. Not all members   will be interested to elaborately fill all details. Integration with existing health databases/EMR/PHR of  the state can help in extracting the relevant data and leveraging them in selecting suitable plan for the  members.
 b.The most preferred method to capture information or arriving at recommended plans for members are    through widgets with just one or two questions per page. A voice over of the questions will give a    feeling of a virtual advisor to the members. It would feel better when the virtual voice over starts of   the conversation with "Hello John! You're your online advisor. Let's get started in finding the most    suitable plan for you..."
3.Provide Clarity 
 a.In the 'must have' category of information that needs to be captured, specify clearly the reason the    information is obligatory. Specify that revealing the medical condition at this stage will not result  in denial of coverage so that the members do not conceal information.
 b.Based on the information captured, the recommended plans must be presented in a format where plan   comparisons can be apples-to-apples. Preferred way of display is a tabular form with the categories of   comparison specified. Options to email selected plans and view printable versions must also be handy.
4.The users must also be presented with additional options and plan recommendations based on the existing medical conditions. This can be related to wellness and preventive care.
5.Utility tools & links -In addition to the online tax subsidy calculators, that is mandated by the ACA for the exchanges, the user must be provided features like health risk assessment, articles related to health conditions, wellness tools - calorie counter, diet plans, exercise log, etc
6.Anytime anywhere - Site accessible in multiple platforms, it can be on a computer, Mobile device or a Kiosk, the site features must be dynamically adjusted and well presented.
7.Collaborate - A lot of us like to read reviews before we purchase a product. Leveraging Web 2.0 features that include blogs, review comments, their recommendations, providing satisfaction ratings will engage members and improve member satisfaction. A site that enables the creation of communities where a better price can be negotiated with the carriers as a bigger group as opposed to going forward individually will also help.
 
Making the Health Insurance exchange simple and intuitive to navigate yet feature rich will form one of the success criteria for a successful exchanges.

• 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.

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.

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

The term accountable care organization (ACO) was coined in the Medicare Shared Savings Program as part of the Patient Protection and Accountable Care Act of year 2010 (PPACA). The program, anchored by the Centers for Medicare & Medicaid Services (CMS), will share annual savings for a population of Medicare beneficiaries with a group of providers who form a provider organization that meets the defined criteria. Such groups are called accountable care organizations (ACOs).

Is ACO thus limited to just consolidation of providers or there is something more to it ? In my point of view, two critical factors which will ensure a proper functioning of ACO -

• Adherence by the individual constituents to a central theme of improving quality of care through innovative practices and collaboration
• Establishing a standard way of performing the clinical practices across the ACO organization

We will be deliberating on these two topics in the next series of blogs.

Coming to the first topic i.e. Adherence to a central theme, the questions that quiz me:
1. How to ensure collaboration among the stakeholders which will result in the patients getting the right and cost effective treatment
2. How will the collaboration exceed the boundary of each individual participating hospital to the level of the accountable care organization

To me, the major roadblocks in ensuring collaboration are the lack of defined processes and supporting systems and a right attitude from the provider. The simple example would be a patient visiting different doctors with the diagnosis and medication information not being shared among the doctors. This might result in duplicate procedures resulting in higher costs.  The medicines prescribed by doctors can create side effects due to lack of knowledge of other medication being taken by the patient. A process needs to be established which will keep track of a patient from the minute of entry to a provider facility to the diagnosis phase. All the medical test results and prescriptions need to be made available on demand. The doctors need to make every attempt to understand the patients by thoroughly looking at the patient history including patient genetics. This is achievable if the providers change the mindset which is caring for volume without looking at the quality of care. The ACO organization must enforce this through a central focus. Building provider awareness is the key. And all these are not achievable by the providers manually and there is a need of robust infrastructure to support.