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May 10, 2013 Readers Write No Comments

Managing Total Medical Expense While Improving Health Outcomes
By Michael Gleeson

5-10-2013 8-53-34 PM

As our healthcare system evolves and payment reform expands, providers are forced to deliver higher quality care at a lower cost to curb explosive growth in national expenditures seen in past decades. As a result of this paradigm shift, the industry is responding.

In order to accommodate the incentives and priorities set forth by the Affordable Care Act (ACA), health systems must elevate the importance of primary care. This care model is shifting, with many adopting a patient-centric “Medical Home” approach to patient management. This new model emphasizes cross-provider care coordination, risk-stratified patient management, and proactive, preventative care.

Organizations are also using data more effectively. Increased adoption of electronic health records (EHRs), has led to valuable clinical data that can be mined and analyzed to inform health plans and providers on both their patient population as well as clinician behavior. However, the problem is that it isn’t being mined correctly. By integrating claims and clinical data, building trust and acceptance by care delivery professionals, and reorganizing care teams around actionable information, health systems will start demonstrating reductions in medical costs while improving patient outcomes.

So where should you start?

The four key pillars for success outlined below focus on improving health outcomes and managing total medical expense as critical elements in achieving lasting change within the practice.

Building Trust and Sharing Data

Despite significant investment in technology and data sharing by health systems, health plans and most primary care providers still have no visibility into their patients’ activity outside the four walls. And some health systems are hesitant to share data and/or performance with their counterparts, so as a result, it’s important to do the following when integrating with the network:

  • Create data governance policies. It is important to have a policy that dictates the use and exchange of shared data.
  • Establish role-based security and blinded data policies. This is a good rule for those who are apprehensive to share information. Not everything needs to be shared in order to drive change.
  • Data validation. Assessments to ensure that the data presented to the practice accurately reflects the activities at the point of care is critical to building trust.

Patient Attribution and Outreach

Quality improvement programs are often hindered by the challenge of accurate patient designation. If you can’t accurately identify who is responsible for a patient, you can’t improve the care rendered to them. Health plans often provide member rosters, but these can be large, burdensome to work with, and are often wrong.

It’s important to implement a system that will absorb the membership files from multiple plans, sync this data with the EHR and Practice Management data, and generate a list of members who are inaccurately attributed. The upkeep on this process, once it’s started, can be done monthly and will only take a couple of hours. With the attribution problem solved, the practice can reach out to the non-engaging patients it was responsible for and re-immerse them in primary care.

Fast, Accurate, and Actionable Data

In the whirlwind of external data feeds and complex EHR data structures, finding meaning can be a long process. Utilizing a flexible, transparent and vendor-agnostic data warehouse system allows information from multiple EHR feeds and claims files to aggregate on a nightly basis. This data is merged into a simple, patient-centered data model for reporting and analytics use. A focus on the EHR’s clinical data ensures near real-time analysis and greater relevance to the providers and care teams, resulting in more accurate and efficient patient results that can be monitored accordingly.

Transforming Clinical Care Teams

Even with access to timely and accurate data, practices can still struggle to improve outcomes because of inadequately aligned care teams. Providers are burdened with excessive documentation requirements in poorly optimized clinical systems. When a PCP is spending 10+ hours a day documenting in their EHR, they do not have the time and energy to consume the relevant information to drive proactive care management and move the needle on patient performance measures.

Arranging these roles appropriately within the care team maximizes resources and is critical to successful patient care. Medical Assistants should become the primary consumer of reports and act as a quarterback for the team, beyond their role of taking vitals. Using pre-visit planning reports, they should identify care gaps and coordinate with the RN and care manager to ensure the right actions are taken before the patient arrives. This will enhance the interaction and allows all current and potential problems to have the time to be addressed.

The inevitability of healthcare reform is forcing practices nationwide to shift how they view, plan and deliver care. While there is a renewed focus on managing quality and cost containment, this requires health systems of all sizes to master their data assets and align care team roles around the right tools and mandates.

As noted earlier, this charge is not easy. However, many organizations are currently rising to and conquering this challenge by utilizing these four pillars of success. By meticulously positioning themselves in line with this industry transformation, and keeping their goals and attention keenly on improving patient care and dissolving excessive costs, real improvements are being identified in the current health environment.

Michael Gleeson is senior vice president of product strategy for Arcadia Solutions.

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