It was great to listen to industry leaders discuss the topic “Supporting Value-Based Reimbursement Models With IT,” on a panel this week that was one of several really noteworthy panels at the Health IT Summit in San Francisco, sponsored by our sister organization, the Institute for Health Technology Transformation (iHT2). The panel was moderated by Deanne Primozic Kasim, director of research at IDC Health Insights. She was joined by Davin Lundquist, M.D., vice president and CMIO, Physician Integration, Dignity Health (San Francisco); Howard M. Landa, M.D., CMIO at Alameda Health System (Oakland, Calif.); Arien Malec, vice president, strategy and product marketing, at Relay Health (Alpharetta, Ga.); and Steve Shihadeh, senior vice president, North America sales and customer operations, Caradigm (Bellevue, Wash.).
The core discussion was around the plunge into the full range of value-based payment and delivery models now emerging in healthcare. Whether it’s accountable care organizations (ACOs) either through the Medicare Shared Savings Program (MSSP) or the Pioneer ACO Program, both sponsored by the federal Centers for Medicare and Medicaid Services (CMS), or private insurer-based ACOs; or population health management programs; or patient-centered medical homes; bundled payment-based contracts; or any risk-based contracts; making any of those innovative payment and delivery models work, is, well… work.
And part of what is challenging, of course, is aligning physicians in private practice with the goals of any of those types of programs. And the tricky part there, of course, is that the physicians need to have aligned incentives, and also need to be very active participants in data creation and data governance, and in performance improvement work that is data-driven. But of course, it’s all harder than it sounds in theory, and also, very much a “chicken-or-egg” problem when it comes down to it, because physicians often won’t feel incented to collaborate on such initiatives unless they have actionable data, but at the same time, the only way to surround them with actionable data is to get one’s physicians to participate in the creation, collection, and analysis of that data to begin with, so that they do feel motivated to change behaviors and practices, with said data.
Still, as Dignity Health’s Lundquist noted, the announcement coming out of the Department of Health and Human Services in January “that they will be moving to value in a few years, signaled to us that we shouldn’t hold off long” on preparing for that shift. “We do have tons of accountable care in the Sacramento area,” he said, referring to Dignity Health’s accountable care organization (ACO) involvements in that region. Meanwhile, he added, “Down in Ventura [in Southern California] where I am, probably half of our contracts are capitated. And many of our hospitals have co-management programs.” So clearly, Lundquist and his colleagues are moving forward on multiple fronts.
Of course, there are resource issues; as Alameda County’s Landa noted, his organization is perpetually resource-strapped, which necessarily means a gradually evolving participation in risk-based contracting and population health management-oriented programs.
The good news, as Lundquist reported, is that “Physicians practicing now are much more accepting of technology. Most who said they would retire before they got onto an EMR have since retired. So I think we’re there,” in terms of physicians’ acceptance of using information systems and information technology in their practices. “But there are still a lot of challenges,” he said. “We kind of went through this with meaningful use. We wondered, how can we get them engaged with this process? How do we create workflows that allow them to accomplish this, without adding a lot of burden? And some of my data informatics partners are always wanting physicians to check more boxes, so we have better data to report on.”
In fact, Lundquist said, referring to the informaticists he and his colleagues work with on clinical performance improvement and other initiatives, “I’ve always told them, we have to align our incentives with what we’re asking our physicians to do. Physicians will find the most efficient way to do their jobs, and if checking boxes doesn’t align with what they need to do, they won’t be checking boxes. But the minute you align incentives so that they will be incented to check boxes, particularly around reimbursement, they will be asking for boxes to click. So you have to align incentives.”
What’s more, said Landa, “Physicians are actually primed to receive accurate information. But instead of being transparent in bringing them the information, we hide it and disguise it. But if there’s one thing we physicians are good at, it’s working with ambiguity and complexity. So we need to get physicians involved in the data creation process. And if the incentives are aligned, and physicians are involved in creating the data processes, that will work.”
So what’s clear is that physicians sit at the nexus of where value-based payment and delivery models meet clinical practice change and the development of data-driven clinical transformation and continuous clinical performance improvement. That is exceedingly important to consider. What is the solution?
The solution lies in leadership and strategy that are reality-grounded and culture-supported in any organization. Physician and other clinician leaders, clinician informaticists, and non-clinician informaticists and other administrative leaders in patient care organizations, are going to need to move things forward together when it comes to developing workable, sustainable value-based payment and delivery models as they touch medical practice. Because simply throwing undigested data at doctors, or loading them down with extra boxes to check inside EHRs, is not going to work, and in fact, could backfire big-time.
All of this is difficult and challenging to execute in the real world, of course. And yet it is also reality. So it’s always good to hear from industry leaders like the members of the iHT2-San Francisco panel on value-based models, as our industry trudges forward on this incredibly important, extremely challenging, journey.