There is little disagreement that moving healthcare reimbursement from fee-for-service reimbursement to a model based on quality and outcomes is the right thing to do. This is true for patients, for the industry, and for the economy.
Yet the transition from FFS models has had minimal success compared to newer and more innovative models such as accountable care organizations and patient centered medical homes. As payers and providers move toward these newer models, they must overcome significant challenges.
For payers, one main issue is getting providers on board and gaining agreement on how quality and value are defined. How will quality be measured? How will providers be reimbursed for it? And what are the best practices given the patient population and unique health issues?
Payer technology is outdated or inflexible. Is the payer's technology an obstacle? How is the Payer sharing its rich data to help providers gain insight into what care is needed and when?
Improving outcomes requires patients to be engaged in their own health. How engaged are patients? How effective are the payer's outreach strategies and engagement tools?
Part of the challenge for providers is there is no single, agreed-upon way to measure quality, much less reimburse for it. Payers may start with commonly-used measures such as HEDIS scores and the Medicare Star program, due to their impact on overall Payer revenues. Even then, it is difficult to standardize care across all instances because there are often health issues unique to each patient.
A patient with diabetes may have different success measures than one with diabetes plus congestive heart failure plus hypertension. Other factors, such as whether they live in their own home or in a long-term care facility, have access to transportation, have family nearby for support and the presence of cultural or socio-economic dynamics outside the provider's control can also have an effect on delivering a quality outcome.
Payers who do use digital engagement technologies often have multiple access points for providers -- one for accessing care plans, another for health risk assessments, a third for pay for performance information and so forth. Office administrators may not be able to see their entire patient roster in one place because it is tied to specific providers, requiring a new login each time. These and other technology obstacles make it difficult for even the most conscientious and dedicated providers to meet their goals.
The best providers and best care plans in the world will have little effect if members don't follow their recommendations. Payers can play a pivotal role reaching out to members with chronic conditions, seniors or other high-risk patients to keep them informed. With models such as ACOs and PCMHs accelerating the transition to quality-based reimbursement, Payers have a unique opportunity to deliver important services to providers and forge true partnerships with them. Providers, however, need assistance navigating the newer value-based reimbursement models.
Dawn Aston is a strategic account executive at Healthx.