The five most common areas of vulnerability for healthcare organizations include the following:
While many hospitals and health systems have very strong relationships with their medical staff, one cannot assume that this is the case. The quality of your relationships with physicians will predict your level of success with managing bundles, ACOs, or any APM. When physicians are not engaged, nothing changes and silos will continue to drive a care delivery model predicated on waste, duplication, and mediocre clinical outcomes.
Big Data and Complex Analytics Necessary to Manage Total Cost of Care
In April 2018, CMS announced that, in its continued efforts toward data transparency, it would be making Medicare Advantage data publicly available in much the same way it has over the last few years with Medicare fee-for-service data. CMS has released more data in the last three years than it has in the 30 years prior in an effort to help providers understand how to begin to manage populations over time. However, while the physical world is three-dimensional, most patient data remains trapped in two-dimensional pages and screens. This gulf between the real world and the digital world prevents doctors, nurses, and patients from exploiting the volumes of information now available to us.
In the near term, a lack of ability to provide physicians and other care team members with information to make decisions at the point of care is a gap for many healthcare organizations. For example, information regarding cost and clinical variation at a provider level is often a big ask for hospital analytics teams, and more than 90 percent of the time it’s a manual data pull that may take weeks to complete. Like it or not, physicians today who are trying to do the right thing for their patients don’t learn of the patient’s outcome until many months after the patient has gone home.
The feedback loop is typically one year in most cases. There are a number of vendors (some better than others) that, for a fee, may either sell you their solution or do knowledge transfer and help you build this competency. Giving physicians bad data is worse than giving them no data, so in this area it is better to go slow and get it right while you build this competency. The end game is building competency to predict and prevent clinical variation. Risk mitigation is not defined as having it all figured out¾instead it is about clear progress in building competency over time.
Pervasive Need for Care Transformation
Often within the same medical group the process for prepping a patient for surgery can be radically different. There is a pervasive lack of understanding when it comes to systems innovation across healthcare. While technology, AI, telemedicine, apps, and other solutions will help, there are some very simple fixes that need to occur in terms of standardization that will enable your success, such as showing physicians their data compared with their internal peer group in an effort to reduce clinical variation, adding metrics to service line report cards related to cost and clinical variation, updating your order sets and protocol to reflect 21st-century medicine, being more prescriptive with discharge ordering, setting expectations with patients around post-discharge care, and patient engagement with respect to medication adherence and ER avoidance. Small fixes can net big returns.
Infrastructure and Competency in Managing Care Transitions
There are two major phenomena that make transitions of care challenging and risky both clinically and financially that most organizations are still trying to figure out. First, the post-acute care workforce is largely under-educated and we have not done enough to support their knowledge development. Second, EHRs are largely non-existent in the post-acute care environment, which at least in part contributes to unnecessary return visits to the ER.
Add to that the fact that leadership roles historically turn over much more rapidly in the post-acute care environment as compared with acute care, which can impede systemic and sustainable change that is so needed in many post-acute care facilities. Making sure your post-acute care partners have the tools necessary to manage total cost of care is important to assess at the outset. If your post-acute network is still under construction, it may make sense to select a population with fewer or no care transitions at the outset and dial up clinical complexity as your network and infrastructure allow for.
The Ability to Influence
This work requires administrative and physician leaders who are visionary and who have influence with their peers. All too often I see physicians for whom leadership is their “Plan B” volunteering to lead this work. You need senior administrative leadership who can remove barriers and break down silos and you need a physician who has broad influence (ideally still practicing) in the organization, as every department from IT to revenue cycle to care management will be critical to your success.
The purpose of identifying risks is to guide you in your planning so that you prioritize improvements in the five areas of risk identified above.
This post was originally published in a special section for the Governance Institute, under the title, “The 21st-Century Patient Is More Complicated but the Remedies Don’t Have to Be: How Bundles and Other Innovations in Healthcare Payment Are Offering New Promise for Care Delivery,” by Deirdre M. Baggot, Ph.D., M.B.A., RN.