5 Steps Toward Accountable Care

Many hospitals are attempting to both save money and move toward population health management. One hospital in Massachusetts accomplished both: It achieved $3 million in savings and had 32 percent fewer high-risk population members at the end of just one year.

The hospital did this by following a five step plan to gather, interpret and use data to identify which potential interventions or process changes would have the most impact on patient outcomes and cost of care. The plan was outlined in a white paper by Cammack LaRhette.

Erin O'Connor, Esq., is the lead engagement manager from Cammack LaRhette that worked with this hospital. She says the organization used the five steps on its self-insured employee health plan, but the steps could be assigned to an outside population as well.

Here, she walks through five critical steps to achieve savings and reduce the number of high-risk population members.

1. Aggregate data. The data needs to include information beyond the electronic medical record and outside of the hospital's facilities in order to get a complete picture of a patient's health history. "The only information in EMR systems happens in the hospital's own four walls or the physician office – and sometimes, those two systems are not connected either," Ms. O'Connor says, which is not enough information. In this instance, the hospital brought in claims data from outside of the organization so physicians could get a full view of what was happening to their patients outside of the organization, such as getting prescriptions or tests done by another physician.

Overall, the data included claims data from medical and prescription carriers, laboratory values from inside the hospital, biometric screening data, health risk assessment results and provider information and affiliation.

2. Analyze data to produce actionable information. The data should be analyzed from the perspective of how to save costs, improve health and produce an improved patient care experience, according to Ms. O'Connor. Then, the data can be quantified, so the organization can see what actions will get the most return for the effort.

One way to produce actionable data is to slice the data based on patients in certain risk factors based on physician practices and geography. "We can say, 'these patients live here and have a higher-than-average risk score, so what can we do for these patients that impact them in those three ways?'" Ms. O'Connor says.

3. Value the identified opportunities and prioritize action items based on value. During this step, a hospital should determine which actions create the greatest potential value for the organization. Once Cammack LaRhette analyzed data for this particular client, it became clear that the use of the hospital's own physicians and facilities could have been higher. According to the white paper, Cammack LaRhette also found opportunities to reduce variation in physicians' referrals and prescribing patterns, improve patient compliance with evidence-based medicine guidelines and increase patient engagement in health risk identification and chronic illness management.

Once the opportunities are identified, hospitals should determine which ones will result in the greatest return on investment and then focus energy there.

4. Change the plan design to drive services to the hospital and its physicians. One of the goals the client hospital chose to act on was to drive more members of the employee plan to use the hospital and its physicians. "There were a lot of opportunities based on the geography of patients and dependents…and they had enough physicians and a growth strategy for the network to engage more patients," Ms. O'Connor says.

The white paper explains that the hospital, with the help of their consulting team, reorganized the insurance plan to have members pay less out-of-pocket if they used the hospital's pharmacy, facilities and physicians, thus making it more attractive for the patients to use the hospital's facilities.

According to Ms. O'Connor, implementing this resulted in half of the hospital's savings.

5. Take ownership of medical management services. In this case, the hospital took utilization management programs away from the insurance carrier and had an independent third-party company manage them, with medical leadership from the hospital overseeing the services.

One of the critical differences between having the insurer and the third party in charge of the programs is that the third party was able to counsel members on the financial implications of using a provider outside of the domestic network. "This impacts hugely on utilization," Ms. O'Connor says. "Contractually, insurance companies cannot steer [patients] to any one facility or physician."

The client hospital also carved disease and care management out from the insurer and took over those functions using the same independent third party that provides a holistic, integrated care management program. The nurses work with each other and work with the patient, not the patient's "disease" or "case". The hospital participated in the hiring and selection of the nurses to perform care management and integrated them into the organization's community, making the nurses highly accessible to the high-risk members and their physicians in the population. The nurses worked closely with both providers and patients to manage care, another key factor in the success. "The nurses spend a significant amount of time with providers, helping them to manage their patients in between visits to improve health literacy, compliance and utilization of resources," says Ms. O'Connor

This step resulted in the other half of the hospital's savings, according to Ms. O'Connor.

Following the five steps is only the beginning of a journey to accountable care. "This starts the process of taking ownership for population health management and creating infrastructure for accountable care," she says. "You can't build to accountable care unless you do these things first. This is the bare foundation."

Once set, the next step for hospitals is to have an ongoing quality or performance improvement process that continues to review progress, acquire new data, mine the data for new opportunities, value those opportunities, and then execute; always mindful of how the results are measured.

More Articles on Population Health Management:

Stratify and Manage Your Emergency Patient Populations: The Importance of Streamlined Follow-up Communication
Coordinating Care for the Chronically Ill Through Care Networks
Managing Population Health: Where Should Hospitals Begin?

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