In this ongoing series on enabling team based care, we’re looking at how technology and human factors impact successful execution. As a framework, we’re applying the principles outlined by the Institute of Medicine for team-based care:
- Shared Goals between both patient and the care team
- Clear Roles and expectations for all stakeholders
- Mutual Trust between all members of the team
- Effective Communication between all stakeholders and across all care settings
- Measurable Processes and Outcomes to track and improve performance
In a previous post, we discussed the importance of Effective Communication. Once you’re communicating, what needs to be measured?
Well run systems enabled by technology are going to be better at achieving the Triple Aim in healthcare: improved health of populations, improved patient experience and reduced costs. It is the mantra of progressive medicine and while the aims are simple to articulate, achieving them and measuring progress is much harder. Measurement is done in different ways today. There are great variations in the type of contracts negotiated as all parties are in very different stages of sophistication and market dynamics are very different, so we’ll talk about a few programs and how their performance can measured at a high level and some of the practical considerations around increasing performance once you are successfully measuring it, but the strategies for success have to be adapted based on context.
A number of payers have been experimenting with Pay for Performance, sometimes called P4P contracts with their provider partners. Very popular with private insurers as well as Medicare and Medicaid, these are often a first step in building the systems and competencies required to take on greater responsibility for patient care. These types of contracts are typically negotiated with a standard fee-for-service rate schedule, so the fees paid to the provider are still on a procedure basis, but with the addition of certain target metrics to be achieved to gain an additional payment on top of the contracted rate. Typically, these targets prioritize preventative measures like appropriate immunizations and screenings that have the potential of identifying illness earlier and hopefully, reducing the burden of treating it while it is still early. These types of contracts typically allow providers to build the information systems and changes in workflow that are foundational to taking on additional risk (and hopefully reward) in the future.
P4P is typically the easiest to understand. If you do and successfully document these activities with your patients, there is a reward available. As with all of the models, access to information in the appropriate context is a key component to success. When it comes to preventative measures, you really want to decide who can best address the issue. If, for example you have a large group of senior citizens that needs to get up to date on immunizations, it may be easier to send a staffer to a community center in a central area and make a day of it. You would also want some reminder of outstanding items available to the provider when they have the patient in the office for other issues, so that you can maximize the time on-site. One often overlooked consideration is appropriate documentation – sometimes a patient has already received their immunization, for example at a health fair – a governance structure and workflow that rewards performance AND ensures care is not duplicated is crucial.
More advanced contracts built on a P4P foundation involve the development of targets for cost and utilization of services while still maintaining appropriate access to high-quality care. Typically, historical trends for utilization are developed and the provider can share in any savings accrued for reducing the rate of growth, again while ensuring patients receive required care. Typically, this access is measured by preventative screenings, appropriate medications and treatments supported by current research, outcome measures like lab results and patient satisfaction (typically a survey administered post-visit). Again, timely data is key; all of the data already mentioned is necessary, additionally population health and predictive analytics come in to play. It becomes critical to stratify higher-risk patients so that they can be prioritized for care to avoid costly hospitalizations or other complications of untreated illness.
Accountable Care Organizations, or ACOs, come in many different variations but all involve providers in multiple settings coming together organizationally to deliver high quality care at the lowest cost. The providers, including hospitals, can develop arrangements that pool the funds saved for distribution at the end of the year, ensuring that all are incentivized to closely and collaboratively manage costs. Here, the risk and the rewards are typically the greatest, as many ACO contracts can have a “downside” so that excessive costs are covered by the ACO. High quality, comprehensive data, typically drawn from claims and clinical information systems are an absolute requirement to project costs, identify areas for improvement and execute on care delivery. Ensuring access to relevant data across multiple settings becomes critical as well so that each member of the team, including the patient, is as engaged as possible in the effort of improving health.
Each of these models progressively ups the performance requirements for providers and require systematic approaches to care delivery. In addition to robust data and analytics, all members of the care team must operate seamlessly, regardless of setting or even time of day to ensure that each member is being fully utilized to his or her full training and potential. Having measurable process drives accountability and offers leadership the best way to identify opportunities for improvement and engage all parties in that effort.