As the U.S. healthcare industry as a whole moves forward towards fundamental change, replacing a volume-driven, fee-for-service-payment-based system with one focused on accountable care, population health, transparency, and value-based payment, both health insurers and providers are finding themselves compelled forward towards new definitions and new horizons. It was in that conext that HCI Editor-in-Chief Mark Hagland interviewed Charles Kennedy, M.D., along with other healthcare leaders, for the May/June cover story of Healthcare Informatics.
Kennedy is the chief population officer at Healthagen LLC, a subsidiary of the Hartford, Conn.-based Aetna, and a health insurer executive helping to guide dozens of accountable care organizations (ACOs). Aetna has been moving forward assertively to collaborate with hospitals and physicians to develp private-market accountable care organizations (ACOs), which generally match the ACO concept evolving forward within several federal programs under the aegis of the Medicare program (the Medicare Shared Savings Program, Pioneer ACO Program, and now also the Next Generation ACO Program).
Hagland interviewed Kennedy for the May/June cover story. Below are excerpts from the extended interview conducted earlier this spring.
What are the greatest challenges involved in trying to leverage data and data analytics for population health work?
The overarching goal of accountable care and value-based payment programs is to move the national payment systems toward rewarding the value of care delivered rather than the volume or complexity of care. The ideal value-based care framework does two things. First, it allows providers organized in an ACO or similar structure to take accountability for each patient in a population. And second, it encompasses the tools to help providers and their patients receive the right care at the right time and place. Done right, these models lead to better health of the individual and the population.
Charles Kennedy, M.D.
One of the most significant challenges to moving to value-based care is complementing the current approach to quality measurement, which is largely retrospective and based on post hoc statistics about the aggregate cohort of patients. Many dashboards, quality measures and electronic records today provide retrospective views and value. What we need now is the real-time insights on a patient’s health, including where they’re going for services and how compliant they are with their care plans, so that we can act on information at the time it will most make a difference in the patient’s care.
And it is challenging to leverage currently available information systems for these purposes, correct?
Yes. Health IT systems that offer the equivalent of a clinical navigation system are woefully under-deployed. Achieving the required information state requires a new HIT infrastructure, supporting integrated administrative, claims and clinical data from all sources reorganized and optimized to assist with value-based care interventions for each individual’s health and care. These records must be not only semantically interoperable, but must also be structured in such a way that provides useful and usable information on each individual patient. Today, however, many EMRs function like electronic file cabinets.
The kind of understanding and usefulness I describe requires advanced knowledge engineering such as ontologies that are purpose-built to re-structure data collected by providers and payers, leverage such knowledge to allow rapid (measured in hours to days not weeks to months) connectivity of any system with information about patients, and provide the ability to trigger actions to assist patients and providers at the time such actions matter. Taking data from lots of sources and lumping it under a patient so that each provider can try to figure out what is going on with the patient each time they need to make a decision is not semantic interoperability.
That really requires moving process closer to being real-time and point-of-care whenever possible, correct?
Yes. Trying to fix all of this after the fact by hiring legions of nurses as care/case managers to try to manually assemble such records and then act upon them using phone calls to doctors and patients and then to use their own clinical skills to attempt to improve the care of the sickest 5 percent of patients not only ignores the other 95% (who are inexorably moving toward the top 5 percent if they are chronically ill), but is too expensive.
Value-based care requires the ability to synthesize all of this information into an easy to consume record of the patient that allows a caregiver, care manager, doctor, or patient to take an action differently than they otherwise would and results in higher patient value. New IT frameworks now exist that perform this function and are just starting to be deployed by health delivery organizations and health plans. The lack of this kind of infrastructure in most organizations still represents the greatest challenge in moving to value-based care.
What are the greatest opportunities in value-based care?
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