Investing in a Medical Home. By Robin Mancuso Managing Director Healthcare Practice

Transcription

1 By Robin Mancuso Managing Director Healthcare Practice

2 A medical home needs to gather, interpret and distribute information about its patients in real time. Several marketplace factors and economic forces are coming together that conspire to position medical homes at the center of the U.S. healthcare delivery system. Two of the strongest influences include healthcare reform, with provisions that are written to support improvements in the quality of care, and the medical home. As the medical home model takes root, it brings the potential to connect physicians and an extended care coordination team with their patients in a responsive, collaborative process that promotes optimal health outcomes. At the core of this technology-powered model, data gathering and analysis makes it possible to manage and share information that helps providers go beyond reactive medicine to drive preventative healthcare. Medical homes also create efficiencies that not only help produce a healthier population, but also reduce expenditures to contain costs. Patients Connection Point to Better Healthcare A medical home is a virtual environment where a physician-led team interacts with patients to deliver comprehensive, continuous medical care. The medical home also acts as the command and control center in the event of an acute episode that requires attention from a broad spectrum of healthcare resources. Within the medical home environment, patients: Learn their numbers: An online biometric and self-reported health assessment provides patients and their physicians with information on blood pressure, cholesterol, satisfaction with work and family life, and other potential health factors. Consult with physicians to establish a quality-of-life plan: Patients listen to their physician evaluate their health status based on the numbers, ask questions about available options and resources that support positive change, and agree to adhere to a set of goals and actions determined by the patient and the physician. Use technology to quantify success in following the plan: Patients track and record activities, decisions and progress against goals through personal monitoring devices, such as a Fitbit and cloud-based applications for smart phones, computers and other devices. Work with personal coaches to stay focused and qualify their success: Not all patients are self-motivated. Some individuals need a partner, friend or family member to help them remember why they wanted to achieve their goals in the first place. Properly trained coaches are partners that often become friends who can help rally family members. HEALTHCARE PRACTICE ARTHUR J. GALLAGHER & CO. JANUARY 2014 :: 2

3 The Essential Foundation of a Medical Home Technology A medical home needs to gather, interpret and distribute information about its patients in real time. What makes this possible is data that resides in a cloud where the home can readily access and share it with the primary physician s team and other potential providers of care to the home s patients. Valuable data can also be found in the records of payer, large employer and government claims, as well as biometric screenings and self-health assessments. Medical homes need to be able to integrate this data into their patient records. Technology solutions can include: Emergency medical records (EMR) Industry-sponsored information exchanges Commercial internet information exchanges Patient portals Actuarially managed data warehouses Evidence-based rules case management systems Reporting, dashboard and analysis packages Quality scorecards Data Analytics A crucial step in establishing a high-performing medical home is turning all available data into actionable information. This information will take different forms, for example: clinical information for care providers and coaching resources; customer preferences for scheduling, billing and coaching; and financial and quality metrics for administrators and auditors. Care providers and coaches will want to stay updated on their assigned patients health profiles and plan participation so they can manage their response to information for optimal outcomes. They need to address: Which patients are my highest priorities? Which patients hold the highest potential for health improvement? How effectively are my high-potential patients meeting their commitment to their quality-of-life plan? The provider team also benefits from determining and revisiting their care delivery approach, by periodically considering: What is my care plan to keep my healthy patients healthy? When I am compared against other providers, is my patient panel appropriately risk adjusted? HEALTHCARE PRACTICE ARTHUR J. GALLAGHER & CO. JANUARY 2014 :: 3

4 Administrators will want to be able to monitor key areas: The overall health of the population they serve Cost and quality measures they are required to report to authorities or shareholders Return on investments in technology, training and process improvement Patient satisfaction Data analysis solutions can include: Actuarially filtered, clinically grouped data warehouses Predictive modeling and risk stratification programs Feeds to case management systems Provider and administrator customized dashboards and reports Scorekeeping In addition to administrative scorekeeping, the medical home will need to independently track performance under new pilot payer contracts. Providers should anticipate more per head payments for case management activities and shared savings expectations for chronic populations. Bundled payment deals for certain surgical procedures are also likely to increase, and orthopedic and cardio care seem to be the first targets. These arrangements will present some challenges to providers. Ideally, a successful pilot requires the medical home to satisfy several criteria, such as: Transparent patient attribution that is approved by the provider community Full disclosure of the claims base Detailed calculations of the case-specific trend rate for medical and pharmacy Detailed disclosure of any plan changes made to the attributed block of business Adjustments for large claims Raw medical and pharmacy claims data at the patient and service level Access to actionable data by physicians Risk adjusted dollar targets for physicians HEALTHCARE PRACTICE ARTHUR J. GALLAGHER & CO. JANUARY 2014 :: 4

5 Medical homes will want an independent partner who can: 1. Review the proposed attribution method and target rate development 2. Assess the overall readiness of the network, determine gaps and develop physician recruitment criteria 3. Evaluate and comment on standard reports from the payer 4. Assess current infrastructure to support a medical home or broader accountable care organization framework 5. Develop a formal report on the requirements the group needs to implement to fully support the alternative payment arrangement A crucial step in establishing a highperforming medical home is turning all available data into actionable information. Patient Service the Heart of the Home The engaged patient will be a successful and happy patient. So, it logically follows that everyone in the medical home who influences the patient s experience needs to complete customer service and sensitivity training, demonstrate proficiency in the required skills and consistently meet behavioral standards. It goes without saying that the primary care team needs to be licensed. Beyond that standard requirement, as more and more of the previously uninsured enter the healthcare system, nurses and physician assistants will also benefit from strengthening their patient service skills to work at higher levels. Finally, in-person, internet-based and telephone coaches need training in behavioral health and readiness for change, in addition to physical therapy, nutrition or their other specialties. Customer service solutions may also include push notifications via a patient portal or social media resources to further support delivery of optimal patient service. Summary The magnitude of change that medical homes are poised to bring to the U.S. Healthcare System has not occurred since the introduction of Medicare and Medicaid. In the intervening years since 1965, we have seen a golden age of medicine, outrageous healthcare cost inflation, subpar health metric results when compared to other industrialized countries, infringement into clinical practices by insurance carriers, creation of HMOs and now accountable care. Not long ago it was the carriers that drove change in the healthcare delivery payment structure, but now the government and large employers are joining the conversation. The medical home, where all these forces seem to be converging, represents an investment opportunity for physicians and their teams that puts them at the center of U.S. healthcare, in partnership with their patients and their families. HEALTHCARE PRACTICE ARTHUR J. GALLAGHER & CO. JANUARY 2014 :: 5

6 Robin Mancuso About the Author Robin Mancuso is the Benefits & Human Resources Managing Director for the Healthcare Practice at Arthur J. Gallagher & Co. In his role, Mancuso provides leadership in the identification and assessments of healthcare industry trends and in the development of the resources, services and tools to help healthcare clients successfully navigate and profit from these changes. He has chaired annual industry events and expositions and has presented at a number of venues including ASHHRA (American Society of Healthcare Human Resource Administrators), ASNY (Actuarial Society of Greater New York), HANYS (Hospital Association of New York State) and HHRAM (Healthcare Human Resources Association of Minnesota). Mancuso earned his bachelors from Hamilton College in Clinton, NY and a CEBS designation from the Society of Certified Employee Benefit Specialists. Robin Mancuso Managing Director Healthcare Practice robin_mancuso@ajg.com Consulting and insurance brokerage services to be provided by Gallagher Benefit Services, Inc. and/or its affiliate Gallagher Benefit Services (Canada) Group Inc. Gallagher Benefit Services, Inc. is a licensed insurance agency that does business in California as Gallagher Benefit Services of California Insurance Services and in Massachusetts as Gallagher Benefit Insurance Services. Neither Arthur J. Gallagher & Co., nor its affiliates provide accounting, legal or tax advice Gallagher Benefit Services, Inc. HEALTHCARE PRACTICE ARTHUR J. GALLAGHER & CO. JANUARY 2014 :: 6 Q:\2014\GBS\28\24124A