Thomas J. Van Gilder, M.D., Chief Medical Officer, Transcend Insights
In keeping with its nature as a scientific discipline, medical knowledge and its health care applications advance slowly and not always linearly. New diagnostic tools, new treatments, new ways of delivering care all are carefully studied, tested, and refined before becoming standard.
Today, however, health care is experiencing more rapid change, even disruption. From Artificial Intelligence and gene sequencing to crowd-sourced self-care and new care payment models, health care is changing rapidly. We have an opportunity to guide those changes to achieve a healthier population, better care experiences, and controlled costs.
Significant hurdles exist: an aging and rapidly growing senior population with a high prevalence of costly unhealthy behaviors that strains our current system. Three in every four seniors are living with multiple chronic conditions, the results of health and lifestyle decisions. Reversing the impact of these conditions, accounting for 71 percent of health care spending, must go beyond more technology and clinical services.
The time has come to review, analyze, and accept new payment models that advance individual patient health outcomes to address shortcomings in our present system.
"New diagnostic tools, new treatments, new ways of delivering care all are carefully studied, tested, and refined before becoming standard"
A History of Conflict
At present, physicians, clinicians, and other care professionals who operate in a fee-for-service model are reimbursed for their services, not for patient health outcomes.
Fee-for-service physicians need to convince health plans to pay them for the services they deliver. The relationship between physicians and health plans is generally adversarial. This is not an immutable state.
Value-based care is based on alignment between health plans and physicians. Physicians, clinicians, or hospitals manage the entire health of the population and use evidence-based protocols to deliver personalized care. The physician groups are encouraged to spend health care dollars (and their time) in ways that maximize patient health.
Take the example of a patient living with diabetes. In a value-based model, the health plan and the physician are incentivized to improve health outcomes, not just deliver another service. The physician practice succeeds financially when its patients achieve their health care goals.This type of careis not a passing fad—it is what clinicians and patients deserve and are experiencing. At Humana, 1.65 million individual Medicare Advantage members cared forby physicians and other care providers in a value relationship experienced, on average, fewer hospital inpatient admissions and ER visits.
Where the Data Reside
Roy A. Beveridge, M.D., Chief Medical Officer, Humana
Value-based payments are helping us evolve from a model focused on episodic care. However, the new payment model requires data to fulfill its potential. Data, analyzed to turn numbers into knowledge and knowledge into actionable insights, must be integrated into work flows so the care team can identify moments of influence where they can improve patient health.
For example, a physician group managing the health of seniors, many of whom are living with multiple chronic conditions, must have access not only to the clinical data residing in their own and others’ electronic medical record system (EMRs), they need insights derived from health plan data to see a complete picture of their patients’ health.
Health plan data transcends institutional boundaries—it has information about care delivered in another clinic or even another state; it has data about prescriptions that have been filled and refilled; it has vital demographic data that can reveal determinants of health that go beyond what happens in the clinic or hospital.
The data volumes and variety are massive and require advanced data analytics capabilities to deliver insights that can predict disease progression, find patterns of behavior that lead to better outcomes, and guide patients and clinicians to better experiences and outcomes. Value-based models can drive these results by bringing former adversaries into an aligned partnership.
The Secret is Connectivity
To successfully manage populations, physicians require data analytics capabilities and supporting technologies that enable them to identify ways where they can help the patient better manage his or her chronic condition. Data analytics platforms must be scalable to enable proactive detection of patterns of behavior affecting a patient’s health. Diverse data feeds are needed to support analytics that enable detection of patients requiring complex or higher risk treatments so the right patients receive the most appropriate treatment for them.
We must recognize that today, data is found not just in health claims, and that data sources are still siloed across the health system. Furthermore, some critical data, such as wellness data from fitness and other remote monitoring devices, are not integrated into the broader data picture for most patients.
All of the data affecting a person’s health, from claims information to clinical data to wellness data, must be collected from different health entities in real-time so data analytics can be applied at the right time, at the right place, and for the right patient. For example, at Humana’s Transcend Insights, our support helped our partners locate and identify more than 58.4 million care improvement opportunities, which enabled them, with our support, to close more than 5.4 million gaps in care.
When there is connectivity across the siloes, and real interoperability among systems, data analytics can ensure that we can deliver a better, higher quality form of proactive, holistic care.
One with the Other
In the not-so-distant future, the entire health care industry, from pharma and physicians to hospitals and nursing homes, will deliver value-based care. Value-based health care will be disruptive to our current system—but that is a good thing if it stems the growth of chronic disease, delivers a better experience of care, and helps control costs.
We as physicians know that our understanding of the patients whose health we’re responsible for will benefit in a system that prioritizes results over actions. Moving to this new paradigm of value starts by harnessing the significant potential of data analytics so care professionals can make a difference in real-time.
We need both new care delivery models and technology to support them--because you can’t have one without the other if you want to build a healthier world.