Industry Perspectives — New Care Delivery Models Mold Health Care’s Future

As costs continue to skyrocket and overall quality decreases, the current health care landscape is untenable. In response, the health care marketplace is experiencing a fundamental shift in how health systems are providing care, how patients are growing as informed consumers, and how information systems work to tie everything together.

Driving all of this disruption are some key trends that have emerged over the past few years, such as where care is being delivered, what data are informing those care plans, and how these changes come together to deliver better outcomes at lower costs.

As these trends continue to take shape, data play an even larger role in the care continuum. As a result, the entire ecosystem must fundamentally shift to meet the new status quo.

Health Care Is Moving Out of the Hospital
Due to an increase in different contracting models, reimbursement has become more focused on disease outcomes than transactional services, with health plans and providers sharing the risk. As patients receive care in more settings than ever before, the industry is moving away from the traditional fee-for-service/transactional care provided by a physician and paid for by a separate health plan.

Mounting evidence over the past few years has found that costs escalate and outcomes are generally poor when patients are in the hospital for extended stays. As a result, there is a concentrated effort to keep people out of the hospital as much as possible whether it be through telemedicine or home health care services.

The ascent of telemedicine helps triage symptoms and answer questions remotely, thereby keeping nonemergent cases out of high-cost emergency departments (EDs). With avoidable visits reduced, EDs can return to their true missions—allowing resources to focus on the emergent cases at hand. By providing better emergency triaging in the hospital, health systems can focus on optimizing primary care and urgent care centers, which will become more accessible and available.

Numerous organizations are moving services away from hospitals and clinics. For example, Contessa Health brings together evidence-based home recovery care models for acute care, postacute care, and surgical procedures to safely and effectively keep patients home during treatment.

Recently, there has also been a massive shift in kidney care delivery, with start-ups and incumbents such as DaVita and Fresenius expanding into at-home dialysis care.

Gaining More Control, Owning More Cost
Having gotten smarter about their own health care, more consumers are getting into the game. The majority of patients receive insurance from their employer, a trend that has moved more plans toward high-deductible health savings accounts. While wages have remained largely stagnant, spending on deductibles and copayments has shifted significantly to the average employee and since skyrocketed. Because of this increase in cost burden, patients are forced to behave like consumers and, more than ever, are making buying decisions about health care in the same way they make decisions about other purchases.

Historically, patients have relied on their trusted primary care physician for recommendations on all aspects of health care. Now, patients are using Google to research their symptoms and decide whether they should see a doctor. They search Healthgrades to choose a physician, visit Yelp for practice reviews, consult their insurance carrier’s portal to evaluate pricing and reimbursement options, and book an appointment through ZocDoc.

All of this occurs while they are also reaching out to friends, family, and social media networks for advice, guidance, and recommendations.

In other words, patients are “shopping” for health care, demonstrating allegiance to a brand, and shifting loyalties to competitors when they are dissatisfied. New companies, such as Pillpack (acquired by Amazon for $753 million), Roman, and Capsule, that cater to healthy people and can navigate care from a consumer mindset are having great success in this environment.

Addressing Social Determinants of Health 
Another potential avenue to help control overall health care costs and outcomes is to view patients in terms of not only the conditions they have but also the many environmental factors that influence their ability to live a healthy life.

Among other things, our health is determined not only by genetic factors but also by access to social and economic opportunities; the resources available for support at home, in neighborhoods, and in broader communities; workplace safety; and the accessibility of clean water, food, and air. Social determinants of health (SDOH) are the data sets that hold the attributes to illustrate this information in aggregate.

At this year’s annual America’s Health Insurance Plans conference, Vivek Murthy, MD, the nation’s former surgeon general, linked the opioid crisis and decreasing life expectancy in the United States to disconnection and loneliness. As such, identifying these attributes and acting on them is becoming a leading strategy to control health outcomes. While the health care system is not set up to address food stability and employment security, there has been an increase in initiatives to tackle these and other social factors. Programs such as Healthy People 2020, a Health and Human Services initiative, aim to address SDOH nationwide and to achieve health equity for all.

Innovative health systems are saving money by investing in SDOH. For example, New York’s Montefiore Medical Center is investing in housing for vulnerable patients and Harvard Pilgrim Health Care Foundation works with low- and moderate-income families to gain greater access to fresh, affordable food. Elsewhere, Pennsylvania’s Geisinger Medical Center is working to address SDOH by providing a week’s worth of food for members in need.

Sharing More Data Than Ever Before
In terms of data sharing, health care is notoriously behind other industries. There are many reasons and market dynamics, including the slow adoption of EHRs and security concerns surrounding both the storage and accessibility of personal health information, that have contributed to the lackluster performance. Perceived competitive advantages that keep patient data close to the chest as opposed to sharing with a competitor in an effort to drive interoperability also exacerbate the problem.

However, massive shifts in these dynamics are disrupting health data sharing. The Centers for Medicare & Medicaid Services and the Office of the National Coordinator for Health Information Technology have been making significant progress in developing and deploying policies that incent data sharing among all stakeholders. In fact, in the next six months, every government-sponsored plan will have to be able to provide access to integrated clinical and claims data.

At the same time, patients who are now more in the driver’s seat of their care than ever before are incented to own and share their data. Health care standards developing organization Health Level Seven International, or HL7, has created guidelines to allow the technical component of data sharing. Fast Healthcare Interoperability Resources, or FHIR, is a next-generation standards framework that leverages the latest web standards and applies a tight focus on implementation.

All of this combined with the explosion of data emanating from the latest trends, including health care in the home and increased app and medical device usage, has set up the industry for a complete changeover from minimal data sharing to extensive data sharing.

A Fly in the Ointment
However, this will present a bigger problem with EHRs that are already incomplete, fragmented, and wrought with duplicate patient medical records.

In fact, the Black Book Market Research Mid-Year EHR Consumer Satisfaction Survey 2018 reported that on average, 18% of a health system’s medical records are duplicates (records that belong to the same patient but have not been linked), which means that nearly 1 in 5 patients’ health histories are incomplete at the point of care. In addition, one-third of denied claims are due to inaccurate patient matching, costing the average hospital $1.5 million annually.

As the health care environment fundamentally shifts, the technology that powers the industry must be built for a new generation that includes vast amounts of data. To deliver on the promise of new and emerging data, moving care outside of the hospital, and bridging communication across stakeholders, information systems must empower the sharing and management of health information. This will require not only new standards but also a focus on interoperability across the entire care continuum.

— Mark LaRow is CEO at Verato, which offers cloud-based patient identity matching solutions. As CEO, LaRow is responsible for creating and executing the strategic vision of the company.