During a recent Scottsdale Institute Population Health Summit, health care executives from a variety of organizations came together to discuss the state of the industry, including current challenges, lessons learned and what’s next.
For many years, experts have projected a complete shift to full capitation – although it’s clear that we will continue to live in a fee-for-service (FFS) world for quite a long time, even as the industry makes strides toward value-based care. This environment will result in a mix of programs and not a one-size fits all approach, as there is no pre-defined path for organizations to make this shift.
As health care professionals straddle the chasm between traditional FFS models and value-based care, a critical question emerges: How do organizations manage various risk models? Disruption to payer and care models means that organizations will be forced to live in two worlds – reactive and proactive care – as they try to adapt to business operations without a standard template. The variance between the percentage of patients tied to FFS, Medicare Advantage, shared savings, patient-centered medical homes, full risk and others will continually ebb and flow, requiring adaptable people, processes and technology.
The good news is that these challenges are not wholly unanticipated, and health care professionals have long managed complex business models operating on thin margins. As the market evolves and organizations find the right mix for their population, strategies will be needed for both FFS, full-risk and partial-risk models. Here, we’ve identified four key considerations for organizations to consider as they prepare for the ambiguous future ahead.
Today’s health care organizations are accumulating an overwhelming amount of data, including patient-reported information, social determinants of health, clinical and claims data. With all this information, it can be difficult for organizations to sort out what they do and don’t need – but data is only valuable if it results in informative and actionable results.
Bringing all of this data together to form a longitudinal record – a 360-degree view of each individual – can be key to an organization’s success. This view enables organizations to understand the opportunities for care interventions to ensure quality measures are being met and can provide a deeper level of analytics into areas such as utilization.
The mix of risk-based care, quality and regulatory programs means health systems have a growing need to understand the people and populations of their attributed lives. By anticipating their needs and costs, health systems are better prepared to create programs and plans designed to generate more optimal health outcomes and drive cost savings.
In the complex, ever-evolving health care industry, standardized care is a beacon among health plans, risk contracts and shared savings programs. In a time where health systems and providers are balancing new regulations, health plan variations and individual people and population demands, adhering to a standardized level of care removes some of the complexities, while ensuring quality and safety are paramount. Processes and metrics to define standardized care help to ensure patients receive consistent, quality care, every time.
Clinicians are on the front lines of the patient experience, caught between benefit plans and delivering care. Navigating the various services offered by payers while maintaining standard quality care can result in difficult conversations with patients that clinicians may be unprepared to address.
As business models continue to shift, it’s unlikely that the industry will find a fully capitated, payer-agnostic model, making it difficult to have one identical message for each patient. Clinicians need help navigating the labyrinth of benefit and care options to balance the quality care and benefits for which the patient has paid as the market continues to operate in varied programs.
Engaging with patients goes beyond helping them manage their conditions. Active participation and shared decision-making is vital, and it’s most effective when an individual’s goals are identified in conjunction with the appropriate tools to make it easy and convenient for them to achieve their desired outcomes. For clinicians, engaging patients depends on the insights generated from actionable, measurable data.
But, what approaches facilitate individuals playing a more active role in their health and care? Organizations should focus on identifying services that promote increased engagement and satisfaction, and determine the tools individuals need to support them in their health and well-being.
As we continue to live in this world between FFS and full capitation, managing risk for both big and small populations across payer groups will heavily impact success. Collaboration with patients in a shared decision-making process is a key strategy to align an organization’s quality and outcome goals with the education and goals for each person.
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