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Despite promising emerging care models, and the technologies and infrastructure to support care across multiple settings, the fundamentals of care delivery have not improved substantively in decades. But now the industry has an opportunity to accelerate such change in ways not recognized as realistic prior to the pandemic 

“In some cases, health care takes years to move inches, and in this crisis, we have moved miles within minutes,” said John Driscoll, CEO, CareCentrix. “COVID is driving more consumer choice and more consumer advocacy for new models.”  

Driscoll hosted the Health Evolution virtual gathering Accelerating Future Care Delivery Models. Joining Driscoll were Cheryl Pegus, MD, President & Chief Medical Officer, Cambia Consumer Health Solutions, Deb Rice-Johnson, President, Highmark and Sachin Jain, MD, President and CEO, SCAN Group and SCAN Health Plan.  

The experts discussed the steps payers and providers need to take to drive meaningful and impactful change to care models:  

    • Establish new technology toolkits 
    • Parse data appropriately  
    • Avoid transitions of care black holes 
    • Keep the door open to innovation  

“The future will be new models taking control of the total episode of care,” Pegus said.Whether you’re providing it in the home or via telehealth, you’re managing the entire patient.”  

Establish new technology toolkits  
As recently as six months to a year ago, many of the consumer technologies being used in health care today would have seemed more akin to future looking technologies rather than practicable ways to engage caregivers and patients.   

“We’re shattering stereotypes,” Jain said. “We’re starting to take a big step back and question some fundamental assumptions about what patients will not do, what patients can and cannot tolerate, what their preferences are. We’re discovering that a lot of what we assumed is no longer true. And I think that’s going into how we’re thinking about new care models moving forward at scale.

Health Evolution establishes Work Groups to advance New Models of Care Delivery

Pegus explained that Cambia’s members have been very accepting of receiving care at home and many are asking not to come in for a face-to-face office visit. This has been particularly true of behavioral health and in many other clinical areas as well 

Highmark, for its part, has Clinical Transformation Consultants that it sends out into the field to work with providers in an effort to maximize value-based reimbursement, Rice-Johnson said.  

From artificial intelligence and broadband to self-service tools, telehealth and remote patient monitoring, each type of technology in its own way has gained new traction during the pandemic.  

“Technology solutions have to be part of our new toolkit for providing care. They not only help those who can’t afford multiple modalities, but really have an impact on those who have limited access because of where they live,” Pegus said.“We have the capabilities to understand humancentered techenabled care in this country.  So I’m optimistic about it.”  

Parse data appropriately  
Rice-Johnson said that Highmark has achieved nearly $1 billion in savings via its value-based reimbursement model supported by its analytics suite. The suite, she said, delivers consistent insights to help physicians make informed decisions at the patient level.   

When Highmark started the program, it essentially conducted a data dump on its providers, after which they had more data than they could possibly use insightfully to change a treatment protocol.  

“We’ve worked with providers, we worked with independent physicians, as well as our own physicians from Allegheny Health Network to improve what they need. We were able to talk about what they’re being measured on, whether it’s quality, outcomes, experience, total cost of care,” Rice-Johnson said. And then we listened to them to understand what exactly was important for them to be able to have greater insights into.”  

A challenge for many health care organizations is the lacking back-end infrastructure to analyze incoming data from remote monitoring devices and then engage patients to monitor and modify their care, Jain said, adding that to the list of improvements likely to come out of the pandemic. At the same time, however, payers have information about every provider their members are using, their medications, treatments, all in a unique and individualized way for each person.  

“It’s critical to make sure the physicians have what they need and listen to them to really change and transform care delivery, as well as reimbursement and financing,” Rice-Johnson said.  

Pegus added that payers need to consider investing in the infrastructure for data interoperability to integrate EHRs and newer platforms so primary care and health systems benefit from the data that is being utilized. Payers also need to be able to provide it to them in the bite size pieces that they need, based on their own resources 

“We need to appropriately parse all the data we have so people can actually take advantage of it on the provider side,” Pegus added.  

Avoid transitions of care ‘black holes’ 
A significant concern among all the excitement about new models of care delivery is that the potential to create even more division by adding additional care sites, including some that are not connected to a patient’s ecosystem.  

“One of the black holes is oftentimes the step where someone is sent home with a discharge summary only,” Jain said, adding that the hope is that the patient and caregivers know what happens next or understand that if they don’t they can pick up the phone and call but, in reality, they do not. “That’s where we have these transitional care challenges. That’s where we have a re-admission problem. 

Jain recommended that providers and payers monitor care coordination to make sure they do not create unintended consequences that drive even greater discontinuity than exits today.  

Pegus said that includes identifying what can be effectively monitored in the home, understanding data points that can make a difference when recognized early enough, and considering aspects of people’s daily lives that can be managed better.  

“It’s not just let’s move everything and monitor everything at home. There are some things that we’re monitoring at home where we’re getting actual data that we can act upon that truly impact re-admission or can really help someone know if they need to see a physician versus a telehealth visit,” Pegus said. “And then there’s other data that’s really about how we will improve outcomes around the disease condition.”  

Keep the door open to innovation  
The pandemic response to COVID-19 has yielded rapid accelerations in health care, but what is not yet clear is whether those will last and, if so, which improvements will survive the pandemic.  

What keeps me up at night is the amount of innovation that’s going to be necessary for the rapid pace of change,” Rice-Johnson said. “Keeping the door open is critically important as we transform care delivery and financingYou just can’t get through transformation without innovation.” 

Pegus added that Cambia has witnessed its health system partners and provider groups become very interested in value-based models 

During a previous Health Evolution Executive Briefing with former CMS Administrator Andy Slavitt and former CMS Deputy Administrator and Director of CMMI Adam Boehler, the two said that organizations with more advanced risk-based models in place have thus far fared better than those heavily reliant on fee-for-service as patient volumes dropped during the pandemic. That reality, in turn, has the potential to accelerate the transition to value-based care.  

Exactly how the transition to value-based payment models unfolds remains to be seen, but the necessity to continue investing in and deploying technology and infrastructure to support new models of care delivery.  

“Technology,” Driscoll said, “is critically important as we think about these innovative themes.”  

Whether the innovation is digital in nature or pertains to new  business models, it will require taking bold actions.  

“We have to get out of pilot-itis for things that we know are going to work. I jokingly say that the pilot is a four letter word rather than a five letter word, largely because I think it’s used to basically push off things that we know are the right thing,” Jain said. “We’ve seen that pretty dramatically in the health equity space where we can use pilots to do things to kind of push off actually doing it at scale.”  

To drive new care models, payers and providers will need to build stronger relationships with members and patients. 

“There’s radical agreement in terms of valuebased reimbursement as being a catalyst for changeeven much more and more importantly than COVID,’ Driscoll said.  

Indeed, achieving that will require that payers and providers leverage technology in new ways, manage and disseminate data effectively, better coordinate care and continue innovation.  

We have seen that really well received, not only by our provider partners and the team being the nurses, practitioners, pharmacists, other health professionals, but also consumers. Patients really want a model with a great experience and value,” Pegus said. Rice-Johnson added: “We have to do our part to make sure that we’re advancing care delivery and taking advantage of the innovation that we’re starting to see come down the path to support the clinicians. 

Related articles: 
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Partnerships are enabling Humana, Highmark to transform during COVID-19
How CEOs are reimaging budgets amid COVID-19 


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Tom Sullivan

Tom Sullivan brings more than two decades in editing and journalism experience to Health Evolution. Sullivan most recently served as Editor-in-Chief at HIMSS, leading Healthcare IT News, Health Finance, MobiHealthNews. Prior to HIMSS Media, Sullivan was News Editor of IDG’s InfoWorld, directing a dozen reporters’ coverage for the weekly print publication and daily website.