The Disaggregation of Healthcare and Its Implications for Care Coordination
By Dhruv Vasishtha
Dhruv Vasishtha, MBA is director of product management for PatientPing of Boston, MA.
Of all the changes that are taking place in the healthcare industry, perhaps the most important of all is disaggregation – the unbundling of care — into a more open, local, and transparent model that delivers greater control to patients.
This trend towards disaggregation is a positive one, yielding the potential to make healthcare more dynamic, responsive, and innovative. But it poses challenges as well, particularly in the complex areas of care coordination and patient data flow. As Julie Yoo, a general partner at the venture firm Andreeson Horowitz, noted last year, “We are seeing the fundamental topography of the healthcare industry changing before our eyes, and it will impact all the ways that data flows and operations are run.”
This article will look at the following dynamics that are at play in the healthcare industry as it undergoes disaggregation and the implications for care coordination.
The unbundling of hospitals
How we access healthcare is changing. In the past, when we got sick, we all traveled a similar patient journey. We went to our doctor, or if our symptoms were more serious, we went to the hospital. We got diagnosed and treated and either were hospitalized or returned home.
Today, we have many different points of access to this care beyond the hospital walls. We can receive care from retail clinics, community centers, behavioral health clinics, home healthcare providers, and virtual visits, among other options. COVID-19 has accelerated this trend, making it more acceptable for people to seek accessible, convenient, and affordable care wherever it is available.
Payers are encouraging this shift since care is costly in hospitals and patients increasingly prefer to remain in their homes and receive care conveniently via today’s technologies (telehealth, at-home testing kits, remote monitoring systems) or through medical professionals coming to them. Thanks to these and other technological advancements, along with increased public openness to receiving new methods of care, the boundaries of clinical capacity can now extend beyond traditional physical and geographic lines.
Changing care reimbursement models
The accelerating move away from fee-for-service and toward value-based care models is incentivizing the outsourcing of care to independent providers and shifting the emphasis to products and services that put the patient’s whole care experience first. This trend has similarly accelerated due to COVID-19 as healthcare entities saw how dangerous it was to rely solely on fee-for-service revenues at a time when very few Americans were seeking out care, even if it was necessary.
The US government has also leaned into value-based care, one of the few areas with bipartisan consensus, to create new financial mechanisms that incentivize new types of providers to carve out specific niche of care management and delivery and get paid for it. For example, the Centers for Medicare and Medicaid Innovation (CMMI) created the Direct Contracting Model to expand opportunities for more diverse providers and healthcare organizations to participate in value-based care arrangements for Medicare fee-for-service beneficiaries.
The new Direct Contracting Model, which began on April 1, 2021, provides participants with increased risk options and is an integral component of the Centers for Medicare and Medicaid Services’ (CMS) strategy to redesign primary care as a platform to drive reductions in costs. Rather than outsourcing services, contracts are being made directly with physicians to deliver care and get reimbursed. As a result, new physician groups are popping up that are removed from the PCP or hospital, and these groups are catering to specific populations or types of care to deliver more efficient, effective care.
Primary care provider independence
Related to the changing care reimbursement models noted above, there is a move towards greater physician independence. After years of acquisitions by hospital groups, doctors are launching their own practices or joining with other independent providers in a move away from employed positions. While employment offers physicians security and stability, independence provides them greater autonomy and flexibility and an opportunity to focus on each patient’s individual needs without limitations.
For patients, the trend towards more independent providers means greater choice, improved quality, increased access, and more affordability. However, it also means that care coordination becomes more complex, as their data is no longer centralized or easily accessible when these patients move different physicians and physician groups for care.
The impact on care coordination
As a result of these shifting market dynamics, there is a lot more fragmentation in the market, which has created an increased need for improved care coordination — the ability for provider care team members to collaborate on shared patients to support long-term health, the cornerstone of value-based care. The promise of improved collaboration among providers, overall improvement in care quality, and ultimately successful patient outcomes cannot be realized without a successful patient care coordination program.
Care coordination is also an effective means to reduce wasteful spending. An article in JAMA examining waste in the U.S. healthcare system cited ineffective care coordination contributing up to $80 billion in wasted spend. This is because healthcare is often in silos, which leads to miscommunication, unclear ownership, fragmented patient care, and frequently poor outcomes, particularly among the most vulnerable populations.
An effective care coordination strategy can help to bridge gaps and connect silos among care teams. Key to this is the ability to share real-time information about patients’ care encounters across provider types and care settings. For example, if a patient goes to the emergency department (ED), their healthcare provider should be alerted by admission, discharge, and transfer (ADT) e-notifications that allow them to connect directly with the patient and the hospital care team to share critical details about their medical history. From there, they can determine the appropriate care plan, whether it’s post-acute care (PAC), behavioral health treatment, or visiting with their primary care physician.
In March 2020, CMS finalized the new Interoperability and Patient Access Rule to help hospitals better serve their patients through coordinated and collaborative care and prevent patient readmission. The rule creates a new Condition of Participation (CoP) requiring hospitals, psychiatric hospitals, and critical access hospitals to share electronic ADT based e-notifications with other providers across the care continuum whenever patients have inpatient or emergency department care events. With the May 1, 2021 compliance deadline nearing, this interoperability can not only fill in the gaps in care, but also prevent redundant procedures.
Done correctly, care coordination can drive quality outcomes across the care continuum and lead to other benefits for providers, including:
- Lowering ED utilization.
- Preventing hospital readmissions.
- Preventing unnecessary procedures and tests.
- Eliminating medication errors.
- Treating behavioral health problems holistically.
- Identifying and managing social determinants of health.
The disaggregation of healthcare holds the promise of ushering in a new model of care delivery — one that is cheaper, more personalized, and more cost-effective — while still delivering value. The key to its success lies in ensuring that all participants in the care continuum have access to real-time patient data and the ability to coordinate and collaborate with other providers across care settings during patient encounters. Real-time information can provide participants with a new level of clinical intelligence to successfully prioritize and deploy care coordination services and ensure seamless transitions of care for patients while also creating optimal opportunities to achieve shared savings, delivering on the promise of the new care delivery model.