Accepting financial risk for patient populations means looking to the future

Based on the results of a recent survey of accountable care organizations (ACOs), more providers seem willing to accept financial risk going into 2018 and beyond. While 85 percent of survey participants planned on pursuing a contract with a downside risk (47 shared-savings/loss and 38 percent capitation), only 50 percent have such an agreement now.

Healthcare organizations have always been financially conservative, but why are only half participating in programs with risk-bearing value-based reimbursement? Among the challenges listed in the survey include: reducing costs, engaging physicians, improving data analytics, managing chronic conditions and improving quality. The reason that these challenges seem to be standing in the way of further risk-bearing arrangements is that ACOs are likely still not fully configured and integrated to efficiently and effectively manage populations of patients. More specifically, too many ACOs are:

• trying to close care gaps when they should be pursuing care coordination;
• focused on managing predictable populations instead of those that do not follow the rules;
• relying on a vendor to supply them with the actionable intelligence that improves outcomes and quality.

To become a high-performance ACO, population health management (PHM) must advance beyond these common reactive behaviors and become proactive. This may require workflow redesign, but it will also likely demand equipping providers and administrators with PHM technology that delivers instant insight and enables ACOs to reach their financial and clinical quality objectives.

Patient engagement must be wholly integrated with PHM
Most patient populations follow expected behaviors, even when they have multiple chronic conditions that ACOs want to help them manage. These predictable populations, while technically high-risk or near high-risk, are not where ACOs need to devote their already limited resources. Instead, ACOs should target the “exceptions-to-the-rule” patients – the patients who are disengaged, not adherent or responding to their physicians’ treatment plan and are then arriving in emergency rooms or being admitted to the hospital when it could have been avoided. Those patients are what the ACO’s population health management (PHM) platform needs to automatically identify and help providers intervene with before an adverse event occurs.

Likewise, if an ACO is utilizing its PHM platform just to manage care gaps, they will continually chase those gaps instead of proactively coordinating care and helping the patient successfully manage a recovery or chronic condition. That care coordination includes what we call “care beyond the obvious,” which means the behavioral and mental health and substance abuse counseling that patients need to truly be engaged and reduce their risk level.

To nurture patient engagement, telehealth tools, such as video consultations with providers and remote monitoring, must be integrated with the PHM platform to help the patient stay on-track, but also reduce care costs and improve care quality.

Eliminate outdated reporting and analytics
Although ACOs and other integrated organizations have only implemented reporting and analytics technology in earnest within the last five years, many of those systems are already antiquated. They are old-fashioned because the technology requires too many steps and too much support from the vendor. Or, the system presents so much data that all providers see is unusable clutter on their screens that slows them down and delivers inconclusive results. This can contribute to physician disengagement, which is another challenge highlighted in the ACO survey results.

Instead, the platform itself should be automatically capturing, normalizing and presenting the data, insight and risk profiles that providers and administrators can instantly understand and use to take action. If they need to design a new report, the platform should be so intuitive and reliable that they can easily create it on their own. Ideally, ACOs and other clinically integrated networks should never need to call a vendor for a report because it should be intuitive enough to do it themselves.

Another piece of automated insight that ACOs and clinically integrated organizations should see from their PHM platform is diagnostic coding information that can help improve outcomes and increase revenue. This intelligence is crucial because patients enrolled in an ACO will often see multiple physicians, some outside the organization’s affiliation. These outside physicians may diagnose the patient with conditions that the ACO’s physicians have yet to diagnose. Or, there may be conditions from the previous year that have not been re-verified. Either way, the ACO is leaving money on the table by not keeping diagnosis codes accurate and current. That means the PHM platform should be identifying and alerting ACOs to those codes that need attention so that revenue is not lost.

Accepting risk means being future-minded
Although payment capitation has existed in the industry since, at least, the 1980s with the growth of Health Maintenance Organizations (HMOs), accepting financial risk seems to be brand new in healthcare. Too many organizations, however, are approaching financial risk with solutions from the past.

Today, the inability to track, predict and act on patient behaviors, which plagued the HMOs, is a thing of the past. Using PHM technology we have now to proactively coordinate care, drive clinical decisions and regain lost revenue will make way for artificial intelligence and machine learning capabilities that will likely make existing solutions seem old-fashioned. The sooner ACOs and other organizations start the journey with a future-minded PHM platform, the more secure their future will be.

About the author:
Pranam Ben is the founder and CEO of The Garage

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.

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