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Running the Rapids of Payment Reform

Several years ago, my family and I went on the rafting trip from hell. Actually, that’s an exaggeration. No one was hurt. We neither lost the paddles nor damaged the boat, but it was certainly miserable. The problem was that four of our five family members understand basic physics. The fifth, our then teen-aged son, does not. Consequently, we spent an entire day unable to control the direction of the boat on the river. There was always one person counteracting the steering.

While we all agreed on where we wanted to go, our assumptions and actions were not aligned with that vision, and it showed: we hit a number of rocks, misdirected the boat, got mad at each other, and made the other tour members unhappy.

I’d largely forgotten that day (perhaps intentionally) until some recent conversations related to health payment reform.

It’s never easy to align competing interests and visions. This is the fundamental challenge in nearly all efforts to redesign the U.S. healthcare system. Unfortunately, many of the risk-sharing payment models being implemented of late bear an uncanny resemblance to our family rafting trip. While the participants agree on the vision and have a common set of incentives, they lack the information necessary to behave successfully as a coordinated team.

With my rafting trip in mind, here are some thoughts on what it takes to navigate managed care relationships:

You need to anticipate and steer carefully around the hazards

Shared risk models by any name  – managed care, ACOs, bundled payment, health homes – require tightly coordinated care across settings if they are to both improve patient outcomes and keep participants financially healthy. At any given moment, members of your patient population will experience a change in status that represents an opportunity to intervene and influence the outcome.

An asthmatic may present in the emergency room. An elderly patient may fall. Some of your diabetic members may gain weight. You can plan for these hazards in the abstract, but managing the real events effectively requires timely information and a fully informed care team. That elderly fall victim is likely to spend time in the emergency room, in a hospital bed, in a skilled nursing facility, and under the care of a home health service. Her medication list will need to be reconciled, transportation arranged, and her home environment adjusted to help prevent future falls. The better the entire care and payment team is informed, the more likely it is the patient outcome will be positive, costs will be minimized, and complications avoided.

Everyone needs to move in the same direction

Moving in the same direction requires shared information. Historically, provider and payer organizations have had very different information systems and little incentive to share information with one another. While the health plan has claims for its members, the provider has been the one with the clinical records – but only for the care provided within its organization. Neither has had enough information to manage the health of a population, and certainly no common plan for collaborating. Shared information is essential to working well as a team.

Good communication increases the chance of success

Shared information alone is not enough – it needs to be shared at the right time and in a way that is meaningful to the hearer. It is more effective for a rafter to hear a call of “paddle left,” than repeated screams of “look out!”

Similarly, notification that  a patient has been admitted to the hospital or a preventive test is due needs to be delivered to the care manager in a timely fashion compatible with his workflow and without extraneous information “noise.”

Nearly all of the organizations with which we speak are embarking on the adventure of shared risk agreements, though most are still in the early stages of the journey. The ones that seem most confident have a strong information-sharing infrastructure in place already. These are the ones who are ready to run the rapids as a team. I promise I’ll keep my misaligned family boat off the river and out of their way!



Head of Developer Relations, Data Platforms
医療従事者や患者さんが利用できる技術が増え、医療マネジメントの進化は急速に加速しています - 私たちはどうすればこの流れについていけるのでしょうか?
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