A February 24 discussion among the executives of the hospital system at the value summit based on value focused on the challenges and opportunities they face in the transition to value based on value. They discussed barriers such as data management, infrastructure costs and risk adjustment methodologies, as well as when they hope to focus their efforts in the future.
Rural hospitals can have unique challenges that adopt programs based on value, explained Julie Yaroch, do, president of Aveledica Charles and the Virginia Hickman Hospital in Lenawee County, Michigan. Many of these models require the same information, but have different definitions and different exclusion criteria and different time frames, he said. “Not all these data can be pressed electronically. Much of that is manual. Being a smaller hospital, I also have low volumes in some of the metrics, so I can’t meet the threshold. «
Yaroch also raised the issue of risk adjustment methodology. “Does that completely explain clinical complexity and gravity? It is not just about making a diagnosis and choosing the correct laboratory or the correct procedure. There is much more that enters care. We need to start observing the complexity that a patient brings, ”he said.
Stephen J. Leblanc, Director of Strategy of the Dartmouth Health System in New Hampshire, emphasized that the objectives of the value plan based on value are usually very consistent with the mission of the health system. «We do not want patients to have to appear in our EDS because their chronic disease is not being handled or that needs to be admitted when it could be prevented,» he said. «But it is the execution that is the challenge, right? It is the investment in the infrastructure. Increases the cost of infrastructure, because you want to use those processes in all patients.»
Leblanc talked about facing challenges with multiple contracts with different measures, different ways of measuring the same types of performance data. “We end up just saying that we are not going to pursue each measure. We will choose five or six of the same measures throughout the population of patients. It is much easier for our suppliers and our reports and analysis equipment. «
Dartmouth Health has also seen some challenges with insurance companies with which he works with the hiring of his own care management companies at the same time that the health system is trying to work with patients, which can lead to confusion Around that data. «It is always a great challenge to obtain data on time in a usable format and then be able to do the analysis of all that too,» he said. «I think that sometimes when we are dealing with great payers, they have kind of a unique model for everyone, and that does not always work, depending on the market or the geography in which it is found.»
Leblanc echoed some of the points made by Yaroch that in rural areas, do not have care -in -law services that have a good staff, due to the shortage of the workforce. «We have transport problems. Therefore, we do not always have a place we can get the patient in a timely manner,» he added. “We are fighting through that. We are fighting through certain cost objectives and methodologies and attribution methodologies, where we discover that they hold us for patients who had never seen before. So I think that all that must be resolved as we advance. ”
Taking advantage of the Cleveland Clinic scale
When commenting on data challenges, Wesley Wolfe, Mha, vice president of payment and network strategy, in Cleveland Clinic, said that your organization is lucky enough to have a sufficient scale to be able to make many reports. “But sometimes, we have had to use that scale to force some consistency in some contracts around measures or time frames, just so that we can do it without continuously adding resources for a unique measurement contract somewhere. What we are trying to do is ask: Does this work on a scale? And there must be some consistency in that. «
A problem is the moment of investment versus the recovery rate, Wolfe said. «It’s one thing if you’re in a captured model, and you have some resources entering, you can start taking a part of that capitation and then displaying that for infrastructure needs as you advance,» he said. It is very different to have those same infrastructure needs, and then execute a measurement period of 12 months and a period of exit of six to nine months, and then another period of reconciliation of three to six months with the hope that you » ‘He will have something at the end, when at that time he now has approximately 24 months of investment in the infrastructure. That is much harder to sell when I go to my executive team. «
Panelists were asked to go from the challenges to the opportunities they see in value based on value. Cleveland Clinic Wolfe mentioned taking learned lessons and infrastructure developed for Medicare’s advantage in the administered care of Medicaid.
“It is unlikely that once, at least in the northeast of Ohio, we moved the service rate for service. There are too many patients traveling from the entire state or region or throughout the country so that we can cover everyone in capitation, ”said Wolfe. “So we will probably be living in both worlds, maybe forever. But our strategy is to advance in the area development skills and programs of more than 65 that we can then apply to other populations. They will not be identical, by any section, but as the largest supplier of Medicaid by volume in the state of Ohio, we believe that there are real opportunities once we put our feet better under us, to start looking at the population of Medicaid and think , okay, what is transferable from the largest 65 to that population of Medicaid, and what can be done better? What infrastructure can we build now that we can simply climb and not have to reinvent the wheel, as we move forward to Medicaid?
A team game
Leblanc of Dartmouth Health said that among the greatest opportunities it implies providing more than the care that patients need outside the walls of their hospitals. «The remote monitoring of patients and hospital type initiatives will grow,» he added. I think they are a bit challenging to do them in some geographies, so we have to solve that piece. Most of our contracts are total cost of attention contracts. I am worried in some of the geographies, we have some hospitals that are independent and are reluctant to assume the risk because they are working on really small margins. And often, there are parts of use that can control and pieces that cannot. Suppliers are not built as insurance companies with risk -based capital, etc. Therefore, we have to discover how to be more innovative around the types of models in value based on value. «
Leblanc said that he steps back and thinks about the rate for service and attention based on value, when observing the services provided by Dartmouth. “I say, well, trauma should probably be a rate for the service. And we should have surgical packages, and perhaps for chronic diseases and primary care, you have capitation. So I think there is a mixture of models that we have not discovered how to mix them, and we all gather them in a total cost of attention, and it can be a challenge, ”he said. “I really hope to see more associations between insurers and suppliers, testing different models in different geographies to see how they work. But we have to keep patients healthier to reduce the cost of medical care. We are not going to do it alone in cuts and reducing prices. It will be a team game. «
Yaroch says that in the future I hoped to see how these programs tell a story that drives action plans to build healthier communities throughout the country. “How can we continue sharing ideas about how these programs can also promote a better patient participation? I think it has really helped us with a equipment commitment model, but there is still that aspect of the patient. If these programs can also push the patient’s participation in some way, then together we can move the needle faster and beyond to improve our communities, ”he said.
The things that Yaroch expects to see are specific programs of the size that allow us to participate. He also mentioned the idea of a centralized data repository, to reduce the workload to suppliers, standardized definitions of the metrics so that it is less laborious for smaller hospitals, so it is easier for them to participate.
