The great hope of accountable care is to ensure all required services are delivered while eliminating duplicate or unnecessary services, and investing resources in lower-cost settings of care including the home, ambulatory and subacute care, and the community. Achieving this goal requires resource redistribution toward early diagnosis and prevention, using evidence as the driver for treatment, chronic-care management, avoidance of duplicative or unnecessary tests and procedures, capacity adjustments and transparency of results to support clinical-process improvement. Healthcare needs to move from reacting to patients who come in for care, to being proactive in seeking out patients who should be receiving care. Someone needs to be designated to take on that responsibility for every patient, and be equipped with the tools to make the outreach process efficient and effective.
The fly in the ointment in all of this of course is the fee-for-service model. More broadly, the U.S. is addicted to a piecework system of healthcare, with its strong roots in entrepreneurialism, independent practice and a business model that has rewarded the zealous application of high-tech and specialized services without a commensurate emphasis on what happens outside of the hospital.
It's likely that fee-for-service will be with us for a long time in some fashion. It's simply too entrenched as a part of our system to uproot. It's also equally clear that a new method of payment, as overlay and in some cases as replacement, will have to evolve to address the desperate need for coordination of care in a public health framework and as a fundamental pillar to address the upward spiral of healthcare costs.
Because the government is not addressing this, it's up to providers and payers to embrace these alternatives. They must find the win-win from bundling of services, using Medicaid and Medicare waivers proactively to deal with community health problems, linking with affiliated physicians to build medical homes, investing in the next generation of hospital-physician relationships that are population focused, and yes, accepting global budgets and capitation as a means to the right end—allocating resources where they can do the most good.
There will be several paths to this end. Some organizations will move toward the staff-model structure pioneered by the Mayo and Cleveland clinics. Others will take the leadership in their states to build provider and payer coalitions and establish accountable-care organizations with long-term contracts with Medicaid and commercial insurers. And others will establish new affiliation, contracting and technology-sharing relationships with a broad array of providers so as to be able to deliver next-generation services including bundles, medical-home and chronic-care programs. Some organizations will expand their own managed-care plans and others will launch new ones so as to provide integrated financing and delivery.
Every provider organization should assess their ability to provide the leadership for delivering services to a defined population. While accountable care may seem too far off to worry about, the amount of change requires that organizations start to build the organizational infrastructure and to move forward now. Begin with targeted programs to, for example, improve cross-continuum care for congestive heart failure patients, work in the community to improve chronic care for diabetics or attack childhood obesity in the community. Experiment with bundled payments to address high-cost cases and implement case management to reduce readmissions, while learning to work with affiliated physicians in a new model. All of these will be tests of the organizational changes that will be needed in the new future of coordinated care.
Tom Enders is a managing director with the healthcare group of CSC, a technology consulting firm based in Falls Church, Va.
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