For Value Based Health Care Reform – accountability is the key driver or success factor (Accountable Care Organizations).
Whether employers, providers, payers or even patients – all stakeholders need to understand their individual and collective “accountability”.
Employers have accountability in their benefit design for both access to healthcare providers and their drug or pharmacy benefits:
For Example:
What are the appropriate deductibles for emergency services versus urgent care services ? Should there even be deductibles for PCP visits focused on wellness support ?
What drugs need “0” co-pays for promoting medication adherence for chronic disease or for promoting wellness like smoking cessation drugs ?
Do we have the proper benefit incentives for all the critical prevention measures ? Colorectal Cancer Screening, Mammography, Immunizations for Pneumovax and Shingles in older adults ? Are all these key prevention measures easy to access and for monitoring periodic performance ?
Providers have accountability in effectively managing chronic disease in targeted or attributed populations:
For Example:
Do we have the validated clinical data – decision support data and analytics at the provider level – Primary Care level for supporting PCMH team based care – performance improvement in both clinical outcomes and prevention measures ?
Have we integrated behavioral health, care coordinators, pharmacists, respiratory therapists, palliative care at the PCMH setting to significantly make progress for improving overall health and wellness for high risk patients – avoiding unnecessary readmissions or ER visits ?
Have we identified and collaborated with selected community resource providers to help high risk patients with the related environmental issues – like transportation, nutritition support, social support, etc
Have we investigated and adopted the use of new telehealth technology to monitor high risk patients at home on a daily or weekly basis, avoiding unnecessary trips to the ER or physician’s office ?
Have we solved all the transitions of care issues in the community as patients transfer between skilled nursing, assisted living, hospice, hospital and physician office settings, with no meaningful way to share and look at current and validated clinical data ?
Payers have accountability in partnering and collaborating on new payment models that effectively supports advanced primary care models – PCMH and other models of team based primary care.
For Example:
Medicare, Medicaid, and commercial insurers are all piloting and experimenting with various payment models for providers across the U.S. – some with increasing forms of financial risk – whether shared savings or full capitated risk ?
Have we arrived at models that are predictable and sustainable income models to support team based PCMH ?
Would care coordination PMPM’s be a better predictable income support mechanism for new primary care models than potential shared savings ?
Should we be promoting fully partnered new insurance plans – with the providers and payers in full equity partnerships to deliver new and sustainable value based performance in cost and quality using the resources and tools of both parties in new constructs and design models ?
Should we have self funded employers equally invested in the risk and deliverables with the insurer/TPA and the providers to successfully partner and engage all parties to the new models of payment and delivery that now focus on employee wellness, productivity and an overall culture of a healthier workforce ?
Patients have accountability in understanding and implementing a long term individual and sustainable wellness journey with their families and co-workers in full support.
With social and environmental determinants at the forefront of chronic disease in America, all individuals must become accountable to their own improved health and wellness.
For Example:
Do we have a primary care physician relationship that promotes annual progress and documentation on our prevention and biomarker key measures of health – i.e. – weight (BMI), blood pressure, lipid panel, fasting glucose or HgbA1c, and smoking status ?
Do we and our immediate family have full understanding of what a sustainable wellness journey is comprised of as to diet and nutrition, exercise, rest and stress management ?
Does our employer support a wellness program with proper knowledge and incentives for improved health on an ongoing basis ?
SUMMARY:
Integrating health with healthcare is the next critical phase of healthcare reform for promoting individual wellness and health – including sustainable, improved patient measures and outcomes, a better patient experience in partnership with team based primary care physicians and for critically needed, overall significant cost reduction.
