Thursday, April 28, 2011

The Seven Ingredients Necessary To Successfully Combine Health Care and Insurance Risk

Basic Ingredients
Versions of PowerPoint have been swarming through the Disease Management Care Blog's computer thicker than physicians on the plaid pants at a country club pro shop sale.  That's because it's been busy polishing the April 29 Care Continuum Alliance sponsored presentation on "Accountable Care Organizations: A Toolkit for Success."

And just what will the perspicacious DMCB actually say?  You'll need to either register or get your hands on the post-webinar recording to experience the full monty, but much of it will be shaped by the emerging nexus between a) clinical care and b) insurance risk.   Are you an organization that wants to take on risk and end the year with a surplus? Are you a managed care insurer, an accountable care organization, a capitated multi-specialty clinic or a hospital with "service guarantees?"

Well, says the DMCB, in addition to the full suite of medical services, going to need some, or preferably all, of the following:

1) an ability to collect, compile and act on patient surveys that measure care gaps and the likelihood of an avoidable expensive future event, such as an admission to the hospital.

2) access to high-end predictive analytics that can draw on multiple databases and find correlations between today's patient characteristics and tomorrow's avoidable hospital admissions, emergency room visits or high claims expense.

3) a willingness to use all means necessary to incent patients to enroll and participate in clinical initiatives, from making an appointment to see the primary care provider to using high-tech home-based physiologic monitoring.

4) knowing how to reconcile one-size-fits-all national treatment guidelines with the realities of busy clinic settings, still evolving IT decision support and state-of-the-art shared decision making (SDM).

5) the courage to unleash non-physicians who can appropriately practice at the top of their license under clinical protocols with the support of physicians independent of location or level of care.

6) understanding of a "shared services model," in which some clinical programs are centrally funded and distributed through a provider network.  "Build" or "buy" works equally well.  If you're in a hurry, the DMCB says go long on "buy."

7) robust ongoing measurement tools that repeatedly assess not only clinical and economic outcomes, but quality of life and health behaviors.

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