The rollout of the Medicare Access and CHIP Reauthorization Act (MACRA) marks a fundamental shift in how healthcare providers approach cost and utilization. This value-based mindset is driving new economic models for care, going beyond approaches driven by the Affordable Care Act (ACA), such as accountable care organizations (ACOs). These changes do not end with providers, however; commercial health plans are seeing the effects as well.
As providers adapt to models that pay for quality and outcomes instead of services provided, alignment with insurers is crucial. According to a recent study from Quest Diagnostics and Inovalon, a majority of both physicians (82 percent) and health plan executives (86 percent) agree that alignment is needed more than ever to achieve the goals of value-based care.
Better tools may help the industry move toward alignment that benefits patients. In the Quest Diagnostics study, 85 percent of health plan executives say insurers and providers could accelerate adoption of value-based care by co-investing in health IT (HIT).
The emphasis on the word co-investing is reason for optimism. Many health plans would argue that they’ve borne a disproportionate share of the costs to date having shouldered massive financial burdens of electronic health record (EHR) investments, but these survey results suggest insurers may be willing to help shoulder the cost of future investment in HIT tools.
For both sides of any co-investment, it’s likely there will be a sharp focus on ROI. The experience with EHRs and earlier HIT investments has left some notable scars. Hospital and health system executives will be reluctant to invest in any new technology until they’re convinced there’s clear revenue impact. What’s more, there must be a clear connection to better patient outcomes. Only half of the physicians surveyed (54 percent) said that EHRs have everything they need. More concerning is that 70 percent of respondents said they do not see a clear link between their EHRs and patient outcomes.
In the coming months, especially in the face of initiatives such as MACRA, providers are likely to be much more discerning about their technology investments. They also are unlikely to move away from existing EHR investments, so emerging tools must prove they are complementary. The idea is to extend whatever value is now extracted from an existing EHR without disrupting critically important workflows.
Solutions that are gaining traction today include point-of-care analytics that alert physicians to gaps in quality, risk, utilization, and medical history. Presenting this information within existing workflows can improve care delivery and maximize payment without placing undue burden on clinicians and their staffs. Electronic prior authorization is another example of sound investment that can save significant time and cost. Both practices and health plans can benefit from a technology that addresses denial-related issues before a patient even shows up. This is precisely the type of investment return that providers and health plans would consider to be a wise co-investment.
Wise investments in HIT to support value-based care can’t happen soon enough. The system is becoming more complex, from the specter of declining payment rates to the potential for losses under risk-based agreements. According to the American Hospital Association (AHA), health systems, hospitals, and post-acute providers must comply with 629 discrete regulatory requirements, creating a resource and cost burden. The AHA estimates an average-sized community hospital spends $7.6 million annually complying with regulatory mandates, with more than $700,000 budgeted to quality reporting alone.
Although co-investment is a two-way street, the impetus to get started can come from anywhere. The key is to build the case for ROI that quantifies how benefits will accrue for both the provider and insurer. True co-investment must deliver shared benefits, and the all-important first step is to determine how that can happen and with which technologies.
L. Patrick James, MD, is chief clinical officer of health plans & policy and medical affairs at Quest Diagnostics, Lenexa, Kan.
