As the cost of healthcare continues on its upward trajectory, the calls for accountability grow louder. Consumers demand that care be affordable, accessible and of high quality. Providers believe that the system must provide them with fair reimbursement that is transparent and rewards good performance and quality of care. Payers want providers to practice the type of medicine that keeps patients healthy and meets medical necessity and appropriateness of care. So, who is ultimately responsible for the patient’s health? On whose shoulders does the effectiveness of the healthcare system rest?
As the cost of healthcare continues on its upward trajectory, the calls for accountability grow louder. Consumers demand that care be affordable, accessible and of high quality. Providers believe that the system must provide them with fair reimbursement that is transparent and rewards good performance and quality of care. Payers want providers to practice the type of medicine that keeps patients healthy and meets medical necessity and appropriateness of care. So, who is ultimately responsible for the patient’s health? On whose shoulders does the effectiveness of the healthcare system rest?
A Moving Target
Consumer-directed healthcare — whereby patients take on a greater portion of their medical costs as a way to drive smarter healthcare decision-making — puts the consumer at the center of the accountability equation. Pay-for-performance puts accountability squarely on the provider. Meanwhile, payers must bear a good deal of the burden of responsibility for patient health because they possess the best access of all healthcare constituents to the entire scope of data within the system.
Payers also have the hard-won experience of using that data to drive outcomes. All of these movements, at least in their current incarnations, put an unfair and unrealistic burden on their intended targets without providing the appropriate tools, information and infrastructure to make these movements successful.
Collaborative Accountability
What’s needed is a model by which the different stakeholders agree on their respective responsibilities. Because of each group’s unique position in the healthcare system, and singular strengths, it only makes sense that accountability should be a collective endeavor.
In this model, patient accountability means being a good steward of one’s own health. The first step involves filling out an employer-provided health risk assessment (HRA) and having a regular physical, then using that information to determine a plan of action. That plan of action must be informed by various payer-provided tools, including educational information about medical conditions, disease-specific classes, home-monitoring devices and Web-based tools that help patients track their medical progress.
For example, if you are overweight or a smoker, your health plan will pay for weight management classes or smoking cessation classes, and reward success by lowering your premium. Similarly, if you are diabetic, have congestive heart failure or are hypertensive, you will be offered help with managing your conditions. And again, your premium level is tied to your actions, so accountability means taking control of your health, with the appropriate incentives attached.
This is a cost-neutral proposition, as incentives would be offset by increased premiums for unhealthy choices. The wisest health choices reap even larger long-term rewards in the form of better health outcomes and reduced medical costs through improved self-management.
Employers play an important role in this model, by not only providing tools like HRAs, but also by monitoring the health status of their entire employee population and being alert to health trends that may require intervention; for example, offering an onsite smoking cessation program.
Providers — both physicians and hospitals — should share the responsibility for health outcomes; and they must do this not only by delivering superb episodic care, but also by helping patients modify unhealthy behaviors, practicing preventive medicine and expertly managing chronic disease. Chronic illnesses, according to the Dartmouth Atlas, cause seven out of 10 American deaths and account for 75 percent of U.S. healthcare expenditures. Until we do a better job of caring for patients with chronic conditions, morbidity and mortality rates will continue to belie the fact that we are one of the most resource-rich, medically sophisticated healthcare systems in the world.
Here’s where the payers takes on a new role. As the repository of most of healthcare’s data — from clinical content to claims data, from laboratory values to benefit and eligibility information — health plans are the stakeholders who can most easily provide the infrastructure and technology to bring together financial and clinical information at the point of care. This can assist providers in ascertaining not only the short-term medical needs of their patients, but the long-term, big picture needs as well. Furthermore, because few providers can afford this type of technology, it’s incumbent upon the payer to play a significant role in the funding.
These payer-provided tools would help care givers manage their patients across the continuum of care and include electronic health records; telephonic services to triage patients and alert providers for follow ups and, hopefully, avoid unnecessary emergency department visits; and disease management nurses to counsel chronically ill patients. In many ways, this is a return to the old model of the family physician — a trusted confidante who spent enough time with patients to uncover issues that may not have been immediately apparent, and considered counseling and education part of doctoring.
These days, physicians are trained to treat patients episodically, and our reimbursement system reflects this, so this new approach will represent a huge paradigm shift for many providers. Benefit designs and reimbursement systems are going to have to reflect this change, by clearly outlining physicians’ responsibilities in this new model and adequately compensating them.
Payment and Execution
Where will the money come from to support this new paradigm? With a health system as huge and complex as ours, and total healthcare spending in 2007 at an estimated $2.26 trillion (“National Health Expenditures, Forecast summary and selected tables,” Office of the Actuary in the Centers for Medicare & Medicaid Services, 2008, accessed March 20, 2008), there are many promising areas for savings. Eliminating fraud and abuse, which currently costs the system about $90 billion a year, is one promising area. Another would be managing molecular diagnostic testing; an exploding area that currently represents $4 billion in medical costs per anum. Additionally, once provider/payers better manage their patients, chronic illnesses will be better controlled, saving money on treatment and hospitalization.
However, even with available funds, we face the challenge of securing buy-in from the various constituents. We must focus on changing payer/provider behavior and building trust between these groups; and consumers should be at the table too. To accomplish this we will also need boundaries and measurable outcomes. As healthcare is delivered locally, an appropriate plan of action would be to define and execute a demonstration project with a specific population, such as Medicaid recipients; HIV or end-stage renal failure patients, to build up processes and technology. This endeavor could become a proof point from which to build trust and base larger future initiatives.
Stakeholders in the healthcare system need to collaborate more effectively; focus on administrative, economic and clinical outcomes, and use technology to facilitate all of this. Accountability in healthcare has been a moving target for too long, as the burden has shifted across stakeholders. It’s time to move beyond that unstable model to one where each constituency draws on its strengths to create a model of collaborative accountability that benefits patients as well as the entire healthcare system.
