Laura is the editorial director of The American Journal of Managed Care® (AJMC®) and all its brands, including The American Journal of Accountable Care®, Evidence-Based Oncology™, and The Center for Biosimilars®. She has been working on AJMC® since 2014 and has been with AJMC®'s parent company, MJH Life Sciences, since 2011. She has an MA in business and economic reporting from New York University.
In the next 5 to 10 years, providers and health systems need to be thinking about how all the pieces of a new system that delivers holistic, value-based care fit together, said Will Shrank, MD, chief medical officer, Humana, during the opening plenary at the National Association of ACOs fall meeting.
In 5 to 10 years, when the United States has moved farther along the path to value-based care, it is going to have to content with a host of new challenges and questions regarding how the different pieces of care delivery fit together, explained Will Shrank, MD, chief medical officer, Humana, during the opening plenary at the National Association of ACOs fall meeting, held September 25-27 in Washington, DC.
The questions of today are ones regarding how fast the US health system can transform care, how providers take care of some patients in fee for service and others in value-based care, and how healthcare handles data and analytics.
“These are short-term questions that really speak to the transition to a more holistic approach to value-based care,” Shrank said.
The next stage will be thinking about how all the pieces of this new system fit together. Shrank spent most of his talk highlighting the need for partners and the right way to work with those partners to deliver care.
Accountable care organizations (ACOs) have a lot of low-hanging fruit that they can address to be successful, he acknowledged, such as referral patterns, care management, and data. However, the idea of taking full responsibility for a population requires a total change in the way ACOs, health systems, payers, and other stakeholders relate to patients and members. Now, these organizations have to start thinking about issues they historically either haven’t spent a lot of time on or hadn’t been trained to address.
Shrank highlighted 5 important issues that providers and systems will have to get a handle on.
Social determinants of health
While there isn’t a consensus on the exact proportion of health costs that social determinants of health make up—figures are anywhere from 50% to 80% of total costs—there is agreement that social characteristics, dynamics, and determinants “meaningfully impact the health and healthcare costs” of patients, Shrank said.
However, there is less certainty about what to do with that information and how much to invest in addressing social determinants. Humana has ventured into the space through its Bold Goals initiative, which brings together health systems, community organizations, local governments, and consumer advocates in certain key markets to identify all resources in that community to address social needs such as isolation, food insecurity, housing instability, and transportation needs.
“We’re starting to see real benefits in self-reported Healthy Days, but we still do not have clear evidence about what’s the intervention, what’s the investment, and what’s the return on investment to make a really crisp business case,” Shrank admitted. “We’re doing it because we think it’s the right thing to do; we’re doing it because we intrinsically believe it ultimately will provide a return on investment.”
It will be up to health plans with risk for members and ACOs with risk for populations to take the steps to redistribute dollars earmarked for healthcare to address social needs by putting that money into social services with the ultimate goal of reducing total cost of care, he said.
In the ideal scenario, providers and health systems would get daily alerts highlighting those patients who will have an adverse event, but that is not the reality yet in healthcare. Shrank challenged the audience members to find vendors or partners to work with to gain access to those types of predictive analytics tools.
“Your ability to understand risk to target interventions to understand which channels are going to be more effective, to deeply, deeply understand the population you serve, is absolutely going to be at the core of your ability to succeed in ACO models,” he said.
There were good intentions when quality measurements were added into the current system. Health plans and CMS wanted to be able to measure quality and ensure that the right thing was being done for patients. Unfortunately, the current reality is a bigger burden on providers, and created more inefficiencies without developing much better outcomes and health experiences.
Quality measurement has become an expensive aspect of the health system as providers and health systems try to measure data, pull records, find where opportunities exist, and more.
In every other sector of the economy, everything has been moving into the person’s home. Shrank pointed to streaming services and Amazon deliveries to highlight how people can get almost everything in the convenience of their home. Everything except for healthcare.
Home health partnerships have been difficult to set up because providers and ACOs have to think about how to actually deliver that care. Will they hire resources and develop the technology, or will they contract with a vendor? If they do contract, do they ask those organizations to take risk?
“This is a huge opportunity, a huge challenge, and I encourage you to start thinking about this now,” Shrank said.
Pharmacy is the “blind spot” in healthcare and has been the most disappointing space, according to Shrank.
“Prescribers are unaware of the cost of the drugs they prescribe,” he said, and drug costs are not really included in the calculation of most of the value-based models coming out of CMS.
As a result, there is a lack of coordination and integration, and a lack of clear data around the opportunity for savings. Unless providers start to view pharmacy as within their purview and part of their responsibility, they will not change the way they approach prescribing.
Humana included pharmacy into its shared savings model, gave providers specific targets, and educated them on the impact these prescriptions have on spend. For instance, switching 1 brand medication for chronic obstructive pulmonary disease to a new generic could save a practice a couple million dollars.
But when Humana asked providers to make the change, educated them, and encouraged them to make the switch, the portion of prescribes who switched was under 10%.
“Getting doctors to really fundamentally think that pharmacy is their problem is not easy,” Shrank said. “Pharmacy today is the fastest source of rising cost in the US healthcare system. It will continue.”
As ACOs and other delivery models gain more momentum, they will increasingly be challenged with how to get all the people at the table working together. They’ll need to answer questions like the following:
“…I hope that we can have this conversation about how all the players will ultimately fit together so we can make this work as best as we can,” Shrank said.