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 / Autumn 2011 / Issue 64(originally published by Booz & Company)


Transforming Healthcare Delivery

Consumer engagement. Collaboration models need to determine the proper role of healthcare consumers in the overall integration. The objective of increased engagement is for consumers to take a greater degree of ownership in their health and make better, more informed lifestyle and healthcare consumption decisions. The level of consumer participation in collaborative models varies depending on their health status and medical conditions, as well as the level of care they require — for example, consumers can be assigned differing levels of responsibility in their own care by treatment type and level of risk.

The use of consumer engagement to transform care delivery and control costs is common in employer plans. These plans often include value-based benefit designs that motivate employees to make optimal choices in their consumption of care. Workplace incentives for programs such as smoking cessation and weight loss have existed for several years. Some large employers are expanding their efforts by assuming a more proactive role in steering employees toward better healthcare choices. For example, in 2010, home improvement giant Lowe’s Companies Inc. struck a three-year deal with Cleveland Clinic for bundled cardiac care services. To encourage its employees to take advantage of its terms, Lowe’s waives deductible, out-of-pocket costs and pays travel and lodging expenses for employee plan members who are willing to travel to the clinic for qualified cardiac surgery.

Tomorrow’s Healthcare Today

The Lowe’s example is only one of many experiments in the transformation of care delivery under way in the United States. Geisinger Health Plan in Pennsylvania is conducting another: The company is developing disease- and procedure-based products — integrated, end-to-end care bundles that are designed especially for specific diseases, conditions, or procedures, and that span the entire episode of care — under the ProvenCare brand. ProvenCare products, which include packaged solutions for back pain, hip replacements, and cataracts, are supported by bundled payments that cover all professional and hospital services from pre-operative care through 90 days of post-operative care, as well as a “warranty” that covers post-operative complications. Early results are promising, demonstrating reduced lengths of stay and reduced readmissions.

A number of U.S. payors and providers are piloting PCMHs. By increasing provision of preventive care by primary care physicians, PCMHs can reduce the need for high-cost specialty and tertiary care. For example, a PCMH pilot between insurer Humana and Metropolitan Health Networks Inc., which manages a network of physicians in South Florida, reported 33 percent lower hospital readmission rates compared with Medicare readmission rates in its first year.

Several Blue Cross and Blue Shield Association plans are experimenting with new payment schemes. Blue Cross Blue Shield of Massachusetts has implemented an “alternative quality contract” that is one of the largest global payment systems in operation in the United States. Blue Cross and Blue Shield of Minnesota (BCBS MN) has established a promising “shared incentive” partnership with major care-delivery systems that is designed to bring its costs in line with the consumer price index. Toward that end, BCBS MN and its provider partners are restructuring care delivery. For example, some provider systems have begun conducting e-consultations in place of traditional office visits, and BCBS MN is reimbursing them for this cost-saving service. Additionally, the payor is sending staff into hospitals to support case-management activities and help providers plan more seamless care for their patients.

These are all worthy experiments, and they suggest that the will to transform care delivery does indeed exist in many healthcare systems. But these efforts are still in their early stages, and if the U.S. and other nations are to create sustainable healthcare systems, all their stakeholders must continue to develop, test, and refine new collaborative approaches to medical value, seeking to increase care quality and manage costs.

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