Entering the last quarter of 2016, the healthcare industry is firmly entrenched in its shift to value-based care. With MIPS and MACRA on the immediate horizon, the pressure is on providers across all specialties to lower costs, improve quality, and ultimately, ensure a better patient outcome.
With growing attention on the next wave of initiatives to achieve this goal, the question that so many providers are struggling with is how to add value to their current range of patient offerings as fee for service payments steadily decrease.
Due to the technological advances we’ve made as an industry over the past decade, health outcomes (and their ensuing payments) are no longer solely dependent on patients receiving care in traditional settings. Rather, new services are allowing providers to cost-effectively mitigate risk and ensure a better care continuum when patients exist in “blind spots” between visits — a time of heightened risk when the threat of readmission or ED visits rises considerably.
Telehealth presents an interesting solution by diversifying where and how providers can interact with their patients. These services allow medical professionals to check in with patients on a regular basis and essentially replicate the effectiveness of an in-person visit — with many front-line specialties currently utilizing this technology, including cardiology departments, pharmacists and mental health professionals.
Identifying — and Remedying — Existing Care Gaps
According to the Centers for Medicare & Medicaid Services (CMS), two-thirds of Medicare beneficiaries had two or more chronic conditions in 2010, with more than one-third exhibiting four or more conditions. Further, the two-thirds of beneficiaries with two or more chronic conditions accounted for 93% of Medicare spending during this time — many were diagnosed with serious co-morbid illnesses such as hypertension, high cholesterol, heart disease and diabetes.
For healthcare providers and government officials, these numbers demonstrated a clear and dire need to devise ways to keep utilization costs down while also curbing the number of patients exhibiting complications as a result of the ineffective management of their various symptoms.
This concern led to the inception of one of the first — and most prominent — programs under the banner of value-based care: Medicare’s Chronic Care Management (CCM) program. In January 2015, the CMS announced that under this program it would reimburse providers for offering 20-minute monthly telehealth calls to patients with multiple chronic conditions. These sessions must be through a certified medical professional and would only be reimbursed provided they were able to create a comprehensive care plan and document treatments within the patient’s electronic medical record (EMR).
The crux of using any new healthcare technology effectively is identifying and applying its potential towards the best fit for a patient population. As such, CCM is a tangible example of an initiative built around a central technology — telehealth — while also creating guidelines that not only encourage adoption, but also effective progress towards a clinical goal. The comprehensive care plan is at the core of CCM and includes factors and health issues that must be addressed during these telehealth calls such as: a problem list, expected outcome and prognosis, measurable treatment goals, symptom management, planned interventions and numerous more.
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At its most basic, the initiative is truly based around this idea: What does the patient need to stay healthy and happy in their home? With CCM, providers are able to capture a clear snapshot of how patients are progressing in their day-to-day lives, offering their doctors better understanding of how an individual responds to a certain medication, whether they are continuing physical therapy routines or even their general outlook and comprehension of care plans. In some cases, a CCM care coordinator may be able to assist their patient in receiving discounted medications if there is a cost issue revealed during the call.
Since the information is reviewable by the primary-care physician in real-time, doctors are placed in an advantageous situation to not only diagnosis changing health status, but also to order emergency services and interventions that can significantly affect whether the patient has a positive or negative care outcome. While CCM is working to impact a specific patient subset, it is clear that this type of model could be replicated for the numerous and costly patient populations that would benefit from an improved care continuum.
Bringing Data into the Equation
Beyond the day-to-day usefulness of telehealth programs for patient care, providers are most excited about the vast amount of data that can be gathered quickly and efficiently from critical patient populations. With CCM, all relevant clinical information from the call is input directly into the EMR, meaning variables such as medication adherence, malfunctioning medical devices, worsening symptoms and even a broken wheelchair are documented and available for analysis.
As analytics companies and their provider counterparts continue to use advanced machine learning to better sift through amalgamated data, the type of clinical insights gathered from CCM calls will only increase in value and usefulness. As of 2016, there is a tremendous lack of information exploring how various chronic conditions interact with one another, and CCM results could significantly illuminate care gaps and revised guidelines on how to treat these patients. For instance, identifying trends between medication non-adherence and a rise in heart episodes in CCM patients could help providers better understand how to manage these co-morbid conditions.
The value of telehealth is further justified when one realizes that the next phase of MACRA is heavily built around reimbursing providers for not just collecting data, but also applying it meaningfully to drive internal and patient-facing growth. Several of the upcoming MACRA initiatives are aimed at helping providers use their data efficiently and judiciously. Having a deep reservoir of clinical information will enable healthcare facilities to prove their outcomes and, theoretically, get paid for improved care.
As increasing amounts of telehealth and patient-collected data are recorded in EMRs, this clinical wellspring will be absolutely imperative for all stakeholders looking to better manage patients with a high risk of ED visits, hospital readmissions and complications — both in the near future and long-term. The combination of telehealth and CCM is just one partnership working towards an idea of quality, but one that continues to build on demonstrated significant success in its year since inception.
I predict in the coming months we will see a growing use of programs that pay providers to intertwine technology and patient interventions outside the four walls of the doctor’s office. These applications will not only benefit primary-care practices, but also the leading hospitals and health systems that need this data to thrive as we explore what quality will look like in our new era of value-based care.
Krista serves as VP of Clinical Services at Wellbox.