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From Patient to Payer, Managing Risk Across the Continuum

by Timothy Dudley, MD

What does it mean to provide accountable care? Accountable to whom? Am I directly accountable for the outcomes I achieve? And for the money I spend to achieve those outcomes? Yes, I am.

Much has been written about the triple aim of accountable care: lower cost, better outcomes and improved patient experience. We (the health care industry) can do better. I can start.

When my value as a provider is measured by output rather than outcomes, I am clearly incentivized to do more procedures and see more patients. Hence the current trend to pay for value instead of volume as a way to change the trajectory of the health care cost curve.

This is all well and good as a directive for providers, but how do we include patients in the process? What incentives do they have to be involved? Will they experience shorter wait times in the office or the hospital? Can they see any discount on their bill?

We’ve all heard accountable care described as “taking on risk.” Life itself is a series of risks, some involving healthcare: Will I get sick or injured this week? If so, will I recover? Who will I need to see to get better, and how much will it cost?

While I have a clear incentive to avoid injury and illness so I can live my life as fully as possible, I can pass some of my risk on to an insurance company. That insurance company agrees to take some of my money each month in exchange for the promise to pay my bills when I experience a health care problem. They also assure me access to a network of quality health care providers. For its part, the insurance company has an incentive to keep as much money as possible to provide value for its owners and investors.

Insurance companies keep more money when people are healthier and doctors do a good job providing efficient, effective care. Insurance companies directly incentivize patients to stay healthy by giving discounts for getting certain preventive check-ups and paying for things like gym memberships. And they incentivize providers by sharing money saved as a result of the caregivers’ efforts. But how are providers’ incentivizing patients to become more involved in their care?

To succeed in the world of accountable care—and for the future of health care to work, in general—we need all hands on deck. I will need to help my patients avoid some risk, help the insurance companies manage risk, and avoid taking on too much risk myself.

Measuring my patients’ risk requires a registry of high-risk (high-cost) problems. I need to be able to see my patients who have conditions such as hypertension, hyperlipidemia, and diabetes. Then, I need the ability to drill down to those people who have uncontrolled blood pressure, cholesterol and sugar, respectively. Then, armed with that information, I can focus my attention on the highest risk patients.

My high-risk patients can be engaged in this process by the use of tools in the office that allow shared decision-making and then by keeping them involved through the use of technology like an online patient portal. Efforts to reach out to these patients can be customized by tailoring messages for specific populations and sending them out in targeted campaigns.

My colleagues can also be involved through judicious use of tools like a care coordination system that surfaces the most trusted providers in my referral network as I write orders for consultation. As efforts get more sophisticated, I can form groups of providers willing to sign contracts that spell out the mutual requirements of our relationship, including the nature of our communication, clearly defined roles, commitment to cost-effective care, and so on.

Finally, I can analyse results with tools that show me where every dollar has been spent in the care of my patients. Although I can’t control all of that spending, I can look for trends and “hot spots” that I may able to impact.

These are the tools of our health care future. And I believe they’ll help me accomplish all of the above in an efficient and cost effective matter, and will be as valuable as my stethoscope and sphygmomanometer.

Dr. Dudley is a family physician in Denver, Colorado and an athenahealth client.

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