The Affordable Care Act was passed in 2010 with the goals of controlling healthcare costs and decreasing the number of people without health insurance.
While progress has been made to expand coverage (the percentage of uninsured Americans dropped from 17% in 2003 to 12% in 2018), overall expenditures continue to rise.
In the United States today, healthcare comprises about 17.9% of GDP vs. 17.3% prior to the Affordable Care Act, consistent with what has occurred over the last 50 years. This is a frequent topic of discussion on the 2020 campaign trail and there are many varied proposals.
Exactly what form our healthcare payment system will take is an open question, but a continual increase in the percentage of GDP devoted to healthcare isn’t sustainable. Payers, led by CMS, are continuing to look for ways to control costs and the move from a fee-for-service reimbursement system to one focusing on outcomes, commonly referred to as value-based care, is a key component of that strategy.
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The Healthcare Learning and Action Network, a public-private partnership launched by CMS in 2015 to accelerate the transition to alternative payment models, has set a goal of 50% of payments based on value by 2025 for Medicaid and commercial plans and 100% for both Traditional Medicare and Medicare Advantage plans. Succeeding in the face of this transition requires a different approach to healthcare delivery; this is where population health management can help.
As part of the drive to improve outcomes, we need to look at how care is being provided to an entire population no matter how one defines the population. While that process needs to start with the direct provision of medical care, as the care model continues to advance to improve outcomes, additional factors such as social determinants of health need to be considered.
Only about 20% of outcomes are directly affected by clinical care, and 30% by factors such as tobacco use, diet/exercise, and alcohol/drug use, which can be influenced by clinicians. The remaining 50% are environmental and socio-economic factors of which clinicians and care team members need to be aware. We can try to impact these factors by making referrals, but as healthcare providers we need to ensure that we focus on the factors we can clearly impact. We can have the most impact on clinical care and health behaviors.
Keys to success
1) Harmonize data from multiple sources to provide clinicians the most complete view of the patient. The data needs to be presented in a manner that presents information to users without worsening information overload. Some of the changes we have seen in healthcare have contributed to information overload, but while technology has, at times, contributed to the problem, it does have the ability to improve the way care is delivered.
2) Create workflows that are optimized to identify and close gaps in care. There are interventions to treat specific diseases (routine eye exams and monitoring blood sugar for diabetic patients) and general health maintenance items (flu shots and colon cancer screening) which we know work to improve patient outcomes. Workflows need to be optimized across the entire care team so that interventions, like these, are always considered.
3) Leverage every encounter with the patient. Think about why a patient is being seen and where. What can be done to ensure that appropriate interventions are considered even when those interventions are unrelated to the reason the patient is being seen. During flu season, for example, almost any interaction with the healthcare system is an opportunity to ensure that the patient receives a flu shot.
4) Think about patients not being seen. Traditionally, healthcare is provided when a patient chooses to be seen. However, population health management requires addressing all patients, not simply the ones who opt to be seen. A strategy needs to be developed to reach out to the patients who aren’t presenting themselves. Ensuring that these patients receive appropriate interventions is critical when trying to meet outcome-based payment goals.
Taking these steps to focus on outcomes across an entire population will deliver results that are good for clinicians, your organization and, most importantly, patients.
Source: Becker’s Hospital Review