September, 12 2011
By:
Shelley Price, director, HIMSS Payer and Life Sciences Care delivery in the U.S. is fragmented and disjointed and often leaves individuals to coordinate their own care. This lack of coordination results in overuse and underuse of resources, both of which can result in increased costs and decreased quality of care.
A recent focus toward greater accountability for the provision of care will have a profound impact on the delivery of healthcare as it shifts the government’s reimbursement model from fee-for-service to one based on quality and efficiency. Patient care coordination, with the objective of improving overall health status, is seen as a necessary mechanism in bending the cost-curve toward a value-based pay-for-quality system. Accountable care organizations (ACOs) formed under this intent will be responsible for the oversight and coordination of all care for an individual with a particular emphasis on the relationship between a person and his/her primary care provider.
Important transformations are occurring in the healthcare payer space. While numerous, these transformations can best be summarized by the major shift that has taken place in the critical role of payers in the overall healthcare system. The payer has shifted from predominately playing the role of "transaction manager" to one of becoming a true healthcare "informediary" for the purpose of partnering in care delivery to improve health outcomes.
An emerging focus in the payer community is on the concept of sharing risk and reward in partnership to improve patient care and outcomes as envisioned through ACOs. Payers have a wealth of experiences and tools around data analytics and business intelligence that an ACO will need to manage risk more effectively. These tools, infused with clinical data, arguably will be a critical success driver for ACOs.
At the new “Leading From the Future” forum, a thought leadership event on Accountable Care Organizations held during the 2011 Annual HIMSS Conference and Exhibition in Orlando, Florida, a session entitled “ACOs: IT from the Payer Perspective” presented an interactive panel discussion in which a UnitedHealth Group and its delivery system partners described the opportunities and challenges related to health IT infrastructure for ACO development, productive collaboration and optimal coordination of care. The panel discussed how payers can work with delivery system partners to share tools and system capabilities; explored how ACOs are using health IT to develop data reporting capabilities for reporting on quality, costs and physician performance; and furthered the understanding of how payers and ACOs can partner in utilizing health IT to identify and mitigate gaps in patient care, reduce unwarranted variation, and increase efficiencies. A session recording of this event is available through the HIMSS eLearning Academy.
Whether through systems such as medical homes or ACOs, the private payer sector has begun to partner with providers to create various health IT-enabled ‘collaborative’ programs to deliver improved care, quality, and value. For examples of these partnerships, please visit the Payer tab under the HIMSS Accountability for the Provision of Care webpage.
