Risk-Sharing in the Future

From the January 2017 Issue

The only constant in healthcare is change. With that said, even given the uncertainties that lie ahead with a new administration, it’s likely that upside and downside risk-sharing models — including shared savings programs — are here to stay.

Population health-focused models such as accountable care organizations (ACOs) have become increasingly popular, as both government and private payers engage providers to share the potential rewards and risks that come with a focus on decreasing costs while maintaining care quality.

It’s likely that even with healthcare policy changes on the horizon, the move to value-based care will continue to gain momentum. In fact, the U.S. Department of Health and Human Services (HHS) has said that by 2018, its goal is to tie at least 50% of Medicare payments to quality or value through alternative payment models. To date, Medicare ACO programs have been the principal contributor to achieving this goal, according to a Leavitt Partners survey conducted in cooperation with the Accountable Care Learning Collaborative.

Private payers are making the switch, too. While ACOs are often primarily associated with the Centers for Medicare & Medicaid Services (CMS), the majority of ACO patient lives (17.2 million of 28.3 million) are covered by private payers.

Future-Proofed Technology
As with any innovation in healthcare, ACOs have evolved over time-from the original Pioneer ACO Model to the Medicare Shared Savings Program (MSSP), to the Next Generation ACO Model, which includes more downside risk for providers but potentially greater rewards. Also in the mix are episodes of care (EOC), bundled payments and more.

It’s likely that the newer value-based care models will move even further away from the original ACO approach, which will require healthcare organizations to be technologically proactive, with better integration.

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In the coming years, we will see a mix of value-based delivery and payment models on the illness-to-wellness continuum, with a mix of newer ACO models, bundled payments, full risk sharing, upside and downside risk sharing. Essentially, today’s shared-savings model-or any other alternative care model-is going to be an interim one. Therefore, the technology that enables tomorrow’s delivery and payment models must be adaptable, flexible, scalable and future-proofed so that it’s still relevant five, 10 or 20 years from now as care models continue to evolve.

Here’s a sneak peek at innovative approaches that will support shared savings and other risk-bearing models of the future:

• Different ways to share risk: Payers and providers will share risk, both upside and downside, in a variety of ways, and broader ways to do so may emerge. For example, there’s already been some talk about medical device manufacturers — think heart implants or stents — taking on their share of risk for cardiac patients with these devices. Clearly, automation, open-data platforms and data integration are critical to tracking patient outcomes and supporting these types of risk-sharing models.

•Technology that supports many diverse data sets and real-time interactions: Population health management, at the center of shared savings and other value-based care models, has traditionally focused on chronic care and care management solutions, particularly on compliance and the delivery of evidence-based medicine. While those certainly are important considerations, the reality is that patient care is not linear, and technology will need to support the ebb and flow of the human health experience.

Providers and payers also need ready access to genomic, social, environmental and behavioral data sets to drive effective patient care plans. The right systems need to be in place to support real data sets with all of these components so that providers have the right information to achieve IHI’s Triple Aim of healthier populations, lower costs and improved patient experience and outcomes.

• Proactive care models that support population health: Open-data platforms allow all members of the care team to access patients’ full medical records and other key data (i.e., social determinants of health) for better quality, more proactive care.

Preventive care (e.g., screening mammograms) can occur proactively instead of retrospectively when the right systems are in place. Instead of patients making a yearly appointment with a provider for a mammogram, the testing is done prior to the appointment with the provider. Proactive care models also include access to data that helps avoid unnecessary duplicate medical testing and provider appointments.

• Care coordination and transitions of care will be more important than ever: More sophisticated data analytics allow providers and care coordinators to better (and more quickly) identify members of their populations who are high risk. Instead of waiting for payers to identify patients at risk weeks or months after a qualifying event, providers can leverage analytics to build their own cohorts and flag them proactively for real-time interventions that lead to better outcomes.

Patients who are ready to be discharged and have a high risk score based on data analytics can be placed on a care pathway before they leave, with follow-up appointments and calls already scheduled. Emphasis is placed on medication knowledge for adherence and addressing social factors that may affect patient outcomes (e.g., a lack of transportation to a follow-up appointment).

• Documentation requirements may increase, but technology will make it easier: With so many care models emerging, documentation will continue to be important from an accountability perspective. Optimally integrated solutions will align quality measures that have crossover across care models so providers will simply document what they are accountable for and move on to the next patient, without worrying about what documentation ties to which care measure.

ACOs and other healthcare delivery systems can gain flexibility by using dynamic registry capabilities and workflows that grow with them to manage differing shared savings contracts or other risk-bearing relationships. Innovative specialty applications running on top of open-data platforms allow quick action on quality measure reporting that requires pulling data from many disparate provider groups in a short time frame. This capability is especially important when payers don’t provide details on their updated reporting requirements until shortly before they are due.

Making the Triple Aim a Reality
With the evolution in care delivery and payment models, many transitions will need to occur within healthcare organizations related to workflows, governance and change management. Ultimately, technology is the enabler to support it all.

The technology that enables all of these changes must be flexible and adaptable so that it, too, can evolve along with the care models. Healthcare organizations that are equipped with the right technology to change — whether that change is driven by consumer, regulatory or market demands — will drive the care of the future. They will succeed in moving the healthcare community towards the Triple Aim.

Cheryl McKay is chief nursing officer, Orion Health.

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