Even as the value-based care and contracting train rolls forward, experts and patient care leaders continue to debate how to make the entire enterprise more successful. One industry observer believes that the missing ingredient overall is that of extensive patient/healthcare consumer participation and engagement. Asher Perzigian, managing director in the health practice at the New York City-based Accenture consulting firm, spoke recently with Healthcare Innovation Editor-in-Chief Mark Hagland about the need to activate the patient/consumer and make that person far more fully active in their own care management. Below are excerpts from their discussion.
Healthcare leaders and industry observers are discussing the relatively slow pace of change in terms of achieving authentic quality outcomes improvements and cost control. What are you seeing in that regard?
I’ve spent a lot of time on the transformation of healthcare delivery. What it means to be a provider, to compete with retail, to compete with payers. And what I see as a major gap is the failure to make the patient an integral member of the care team.
In that regard, where are we now?
Value-based care programs are often seen as cold and transactional between payers and providers, and don’t consider the patient’s role in decision-making. Patients need to be the chief decision-maker: need to understand costs to them, need to find clinicians that align with their goals, need to know how the outcomes from providers work for them. What if a new mother could choose an OB/gyn using information about outcomes and costs? Patients must not only feel enabled to take part in their own health, but also must feel they have a stake with related incentives.
We’ve been talking about the empowered healthcare consumer for over 30 years now. But what’s different now from three decades ago? Clearly, for one thing, we have and can use data.
If you go back and look at it, despite the growing uptick over the last 30 years, value-based care has failed to move the needle on cost and quality. Going back to the mid-90s, even as more energy was put into value-based care, Americans got sicker, and we have been paying more for healthcare. We absolutely do now have the data and the connections, plus the year-over-year peer-reviewed journals describing the solutions. But I don’t see providers changing clinical workflow, or taking the data to make the next care delivery change, or enabling change from an administrative standpoint.
And this is where things get complicated in large health systems. Is it clinician-led? Administratively led? It needs to be both. How are we taking advantage of the tools and technology in true evidence-based medicine to change outcomes through action at the point of care? Otherwise, it simply becomes an academic question. Specifically, what we can do is that we can improve patient education, through interfaces, that outline coverage, benefits, and what you can do to improve your decision-making. For primary care physicians, we can improve attribution to patient-friendly actions. In any other industry, we talk about loyalty, what it means to be engaged; yet the reality is that we don’t see financial incentives for patients or talk about true loyalty programs or reductions in premiums for weight loss, for example. It’s considered icky, versus what will actually move the needle.
And even when data is available to patients, it’s not really usable, right? Because there is a payer intermediary in the form of the health plan or other payer.
Patients are not appropriately informed or incentivized to make decisions that will lead to the most value. And value is not just dollars and cents, it’s outcomes. There was a study last year in JAMA, and it found that higher MIPS scores did not point to better outcomes. And if you actually look at the number of hospitals compliant with federal price transparency laws, fewer than 40 percent of hospitals were compliant. And then, if you look at, can you access the data, much of it requires more than 15 clicks to find.
There’s a utility element to that, right? Who has the time to do rigorous, comprehensive research on their own?
Yes, and for folks like us, who are blessed with health, the reality is that provider systems aren’t forced to make those changes. There’s also what I call the quality illusion: quality measures in traditional value-based care contracts are not focused on health outcomes that capture an accurate measure of care quality to identify improvement areas, and thus do not impact outcomes as intended.
In that sense, we’re measuring quality based on checking off boxes, right?
We are absolutely measured based on checking off boxes. And all the studies show that process is what we’re measuring, not outcomes. Every single reimbursement model is based on, have you done X, Y, and Z, not on what you’ve achieved. That needs to be changed. Going back to your question, we’ll only continue to see costs rise and outcomes not improve.
How do we change that?
We must include the patient and involve the patient in the process. For providers, we must allow the care team to modify the care model, and publish quality and performance results among providers. We need to ensure competitiveness among providers, and that’s not true now. And we need to incorporate additional patient education programs.
The most advanced patient care organizations have nailed down nurse case management and care management, as one key element in this, correct?
Yes, and that’s not new at all. And we’re not going to grow our way out of the labor challenge. GDP growth attributed to labor costs is 99 percent in healthcare, versus 25 percent in the overall U.S. economy. By 2035, we’ll have a 34,000 shortage of PCPs, even with an increase of 54 percent of PCPs. Technology has to help us. That means that the composition of the average care team needs to change, per outcomes. So patients need to be connected to lower-licensed practitioners on care teams. How do you do that? Number one is what we at Accenture like to call, “The Blank will see you now.” Meaning, you empower those lower-licensed practitioners. Two, we like the Goldilocks panel, determining what level of clinician a patient needs to be seen by. And we’ll solve how we scale the managed care conundrum, and we’ll ultimately be able to utilize data and reach real capacity.
And a key element here is that providers still have to successfully address care management for the most frequent “frequent flyers,” the most complex patients, correct?
All organizations need to be extremely careful about how they think about and talk about and organize around the frequent flyers. They don’t want to drive the intention of not providing needed care. But you can flip the question and say, this isn’t about reducing time served, it’s about ensuring the patients’ needs are met. Do patients feel they’re in the lead role, as it were, in their own health? Are they the chief decision-makers in their own healthcare? If we can connect them to the lowest level of licensure of clinicians for care management, and also utilize the right resources—that’s where our clients are feeling more successful.
And this should be looked at in terms of an end-to-end flow. Clinical nudges are the biggest thing I’ve seen my clients use to maximize their resources. They help patients make decisions. For example, when referring a patient to a specialist, the clinical interface recommends a provider who maximizes patient experience, quality, equity. From a pre-appointment perspective, it’s a call center person maximizing the patient’s options. Or when providers make referrals, their EHR optimizes potential specialists who most fully maximize value. And care navigation here is just one point in time. How do we go from pre-appointment all the way to post-acute care? Providers can get best next-step suggestions. And we have enough data to move past prediction to prescriptive recommendations—what we should do with a particular patient. Those are all real, technological things—clinical nudges that we can do today that the vast majority of organizations aren’t yet doing. It’s all about organizing clinical workflow.
How do you see this landscape changing over the next few years?
I believe we are at a critical moment in time based on our cost pressures, and based on savvier patients/consumers demanding more and having more options. I believe these smart organizations will realize they need to pivot, to truly reinvent their organizations. And we’ll see a lot of organizations fail who are too slow to the game and don’t respond in time. I see hope and failures; but those who succeed will change the definition of value in value-based care. And I’ve spent a lot of time on the transformation of healthcare delivery. What it means to be a provider, to compete with retail, to compete with payers. And it’s clear to me that patient engagement remains problematic.
We’ve also been talking for years about the patient as a member of the care team. Where are we really in the journey of a thousand miles around implementing that concept?
Value-based care programs are often seen as cold and transactional between payers and providers and don’t consider the patient’s role in decision-making. Patients need to be the chief decision-maker: need to understand costs to them, need to find clinicians that align with their goals, need to know how the outcomes from providers work for them. What if a new mother could choose an OB/gyn using information about outcomes and costs? Patients must not only feel enabled to take part in their own health, but also must feel they have a stake with related incentives.
How are we taking advantage of the tools and technology in true evidence-based medicine to change outcomes through action at the point of care? Otherwise, it simply becomes an academic question. Specifically, what we can do is that we can improve patient education, through interfaces, that outline coverage, benefits, and what you can do to improve your decision-making. For PCPs, we can improve attribution to patient-friendly actions. In any other industry, we talk about loyalty, what it means to be engaged; yet the reality is we don’t see financial incentives for patients or talk about true loyalty programs or reductions in premiums for weight loss, for example. It’s considered icky, versus what will actually move the needle.
How do you see this landscape changing over the next few years?
I believe we are at a critical moment in time based on our cost pressures, and based on savvier patients/consumers demanding more and having more options. I believe these smart organizations will realize they need to pivot, to truly reinvent their organizations. And we’ll see a lot of organizations fail who are too slow to the game and don’t respond in time. I see hope and failures; but those who succeed will change the definition of value in value-based care.
