The future state of healthcare certainly holds the promise of better health at lower costs. It’s the current state of evolution that presents the greatest challenge.
In the years ahead, we must learn to manage the health of our populations in order to manage risk. As a mid-sized, sole community provider in Central Virginia, our aim at Centra Health is to own as much of the premium risk as possible for the care that we deliver.
Centra is really three components: a full-service, tertiary-care hospital; a post-acute division with senior rehabilitation and mental health; and a large physician organization with employed primary care specialists. We also have a small commercial insurance company established about 20 years ago and a pilot ACO initiative with the potential to become a key operational model.
Without direct competition in our primary market, we have the ability to look at a sizable landscape and develop a care delivery solution that works across the community. But we know that we’re not going to achieve it through increases in reimbursement or commercial contracts. Nor will it come through regionalization or additional volume. For top-line growth, we must improve our management of premium risk.
Using IT to Integrate Clinical and Financial Data
Risk revolves around data. To take on risk, you need:
- A common health information interchange/centralized data warehouse with patient data that is shared and accessible to enable clinicians to make near- or real-time decisions
- Claims data, along with insurance-like analytics
- Software that provides case managers with the information to support preventive care in the community
Clinically, the bottom line is that our physicians need an information technology approach that helps them make good decisions for the patient and the entire population. Financially, the bottom line is that we must have the data to understand where our costs are and to adjust cost structure accordingly.
Recently, our clinical and financial systems dovetailed neatly through a discovery we made with our self-insurance product, which covers approximately 7,700 employees and their dependents. Using our new analytics solution, our claims data revealed a surprise. We had assumed that diabetes or other chronic diseases were driving costs, but the real driver was asthma. That finding helped us refocus and target this at-risk population with better preventative care.
Now, we’re eager to analyze our Medicare Advantage claims to determine which diseases to target and keep those patients out of the hospital as well.
Targeting Primary Care
Another area of focus is our primary care physician (PCP) constituency. Most PCPs in our market are independent and have not had the opportunity to work with new business models. Many are seeing multiple patients daily just to stay on the razor’s edge of profitability. They simply can’t envision how they’re going to add data management to their practice and still make ends meet.
Here, the interoperability and information exchange between the physicians’ and Centra’s systems comes into play. So does the organization of data, because if standardizing information involves an extra step for busy physicians, they are not likely to do it. The technology solutions have to be available in the right setting and at the right time for physicians to continue to be efficient.
We’re also working to develop and demonstrate metrics that will incent PCPs to target specific areas of chronic disease. At Centra, we’re doing much of that education and modeling right now, working toward our goal of aligning our PCPs around coordinated population health management under a clinically integrated approach.
The Heart of Change: People and Processes
Of course, data alone won’t generate the transformation needed to reach the future state of healthcare. At the heart of this change are people and processes.
To that end, our process engineering department has grown from one person to about 30 individuals—in just eight years. Their work focuses on examining data with the goal of identifying and making improvements in efficiency and workflow.
We’re also using process engineering to better understand the utilization, and financial and social/behavioral drivers of specific patient populations. Currently, our attention is on uninsured and Medicaid patients using ED and inpatient services.
One Size Doesn’t Fit All
Information technology provides key support for managing population health and assuming risk. It strengthens our core competencies for assessing risk, addressing gaps, exchanging information with stakeholders, analyzing costs and predicting resource demands.
But in the end, a “one-size-fits-all” model of delivery for all organizations is unlikely to emerge. Developing new models, sharing successes and advancing our collective understanding are what ultimately will fuel our care evolution.