The need to control healthcare expenditure (per capita Medicare expenditure at $8973) is no longer in doubt. With over 36% of the $599 Billion Medicare spend on inpatient care, almost 19% on post acute care and over 13% on outpatient services healthcare is looking to new business architectures to contain costs as well as maintain quality. Accountable Care Organizations (ACO’s) is one such business model structured from a fee for service to a pay for performance model.
The aim of an ACO is to reduce healthcare costs, improve quality as well enhance patient experience. ACO’s are legal entities that organize around the concept of a patient centered medical home with primary care physicians forming the core who become the focal point for engaging with the patients to participate in driving superior outcomes. The ACO’s enroll healthcare participants in the care continuum who collaborate together in concert to meet the goals of the ACO. These participants would include specialists, extended care providers (skilled nursing, hospice, extended care), physicians, nurse, dieticians and social workers. Primary Care Physicians can participate in only one ACO; the others may participate in more than one ACO.
ACOs may be fully integrated or they may draw members from outside the organization into the legal structure through agreements to complete all needed participants in the care continuum.
ACO’s have shown benefits. Cigna has done a study showing significant savings in Accountable Care Organizations. Michigan’s Value Partnership Program or Blue Shield Blue Cross MA and others have shown promising savings.
Can this shared savings be increased using collaboration, video and Telehealth technologies? There are indicators that it can:
VA has shown a 19% reduction in hospitalization through its Telehealth program
Geisinger Health Plan has shown a 44% reduction in readmissions with Telehealth
Over 75% of Asthma admissions could have been avoided by using Telehealth
The payout to an ACO is calculated as:
Payout to ACO= (Cost Saving) x (Shared Saving %) x (Quality Performance)
An ACO is a business architecture where caregivers need to collaborate in the delivery of care, very closely, across the care continuum. The Primary Care physician needs to remain engaged with the patient as the patient transitions through different touch-points in the care continuum. Patients remain engaged and vested in their own well-being. The physicians will practice at the top of their license leaving certain functions to appropriately trained nursing.
Healthcare IT will play a major role; one of the requirements is for at least 50% of the primary care physicians to be meaningful use users. ACOs also have to demonstrate evidence-based practice. The ACO eco system should collaborate around an EMR that could be delivered on the cloud as a service to the ecosystem.
The ACO needs to identify at-risk patients and maintain close contact. Case Managers or care coordinators will leverage technology to keep the high touch with at risk patients.
Patients also need to have access to their trending health records as well as receive focused education
An ACO can increase its cost savings through immersive video and collaborations:
Care transitions managed through proactive video collaboration between caregivers help in reducing medical errors and re-admissions
With immersive video based collaboration where the specialists and the primary care physician examine a patient at the same time using multi-point Telehealth saves costs. Such interactions also allow the primary care physician to make more informed decisions over a period of time. ACOs can see huge savings through this provider partnership.
Care coordinators can maintain a video based touch with outpatients and direct nursing visits where needed or bring in physicians or specialists into a video consult with the patient avoiding unnecessary visits to an ER
Telehealth can provide specialist access to patients in skilled or extended care facilities cutting down avoidable ER visits
Telehealth solutions that create physician groups can allow the right care provider, based on specialty or language, to provide care where needed
Technology can be leveraged to manage chronic conditions. “No show patients” is a huge drain in the operational waste in healthcare systems. Whether delivering virtual care in mental health situations, or examining patients who have difficulty traveling to clinics, video consults for movement disorder, neurologic or cardiac patients post operative consults – Telehealth can bring down healthcare costs.
Telehealth can allow specialists to avoid travel to remote clinic. The time saved provides efficiencies whereas the additional patients that a specialist can examine in the time saved provides transformational benefits
Structured collaborative education using technologies such as Webex can be more effective than a written brochure
Video, collaboration and Telehealth can also help in increasing the quality performance measures for ACOs:
The ability of a patient using immersive video and collaboration to stay in touch through care coordinators with physicians, specialists, nurses or social workers enhances the patient caregiver experience.
To succeed ACOs have to create appropriate team plays. Collaboration allows ACOs to dynamically build appropriate care teams to manage patients in different care settings. This helps in driving care coordination and patient safety metrics
Appropriate technologies as well as high touch virtual collaboration through immersive video can help with at-risk patients in any care setting. Structured education and trending personal health records drives adherence, compliance and better outcomes.
All that is good but is there an ROI for collaborative solution video and Telehealth? Yes, our ROI models have shown that such solutions can increase shared savings as well as improve the quality metrics.
However, the health of the ROI will depend on a sound network architecture and the investment in appropriate Video and Telehealth solutions:
The Telehealth solution should be scalable. Statistically 20% of the patients are responsible for 80% of the costs. Even with the smallest ACO with 5000 patients that translates to at least 1000 patients that need closer care. Even if 20% of these are at-risk that translates to over 200 patients that need a high touch video collaboration. This besides the Telehealth network across the care continuum of the ACO eco-system.
The Telehealth solution should accommodate and adapt to a variety of tethered and untethered end points as well as bandwidths
The Telehealth solution should be resilient and stay alive in the case of server failure
The Telehealth/Video and Collaboration solution should be built on a medical grade network infrastructure with a solid foundational architecture
The Telehealth solution should be simpler than a telephone to use. Single click collaboration will widen adoption
Primary care physicians and specialist need to collaborate on patients. The Telehealth solution should allow physicians, specialists and radiologists seamless collaboration with medical images without having to exit out of the collaboration session
The Telehealth solution should have the ability to push or pull data to/from EMR’s
ACOs are team plays so the Telehealth solution should allow the primary care physician and a team of specialists or care givers to examine a patient at the same time with vitals being shared to providers that need to see or listen to the telemetry. A variety of telemetry devices will allow different specialist to take advantage of the solution and provide cost saving virtual care
The Telehealth solution should allow grouping of specialists from different systems by specialty, care team or language. The system should abstract all complexities of contact center, collaboration technology, presence, firewall traversal and build these virtual groups as if they existed in one physical organization
Physicians are not always available, the solution should indicate presence status of the care givers so that the available care provider can be brought into a consult when needed
Finally an ACO creates a virtual organization and the Telehealth solution should integrate into the business and IT architecture of the ACO
An ACO is a collaborative organization. Healthcare services will be delivered over the network. The business architecture will implement on the IT and Network architecture; it is important to ensure that the network architecture foundation is strong and secure.
There will be big ACO successes and some not so big. Factors that will drive success are:
Healthcare ICT and careful architecture considerations
Immersive and pervasive collaboration and team play
An ACO creates a new way to deliver care. Process will be key to ensure operational efficiencies. Mapping out the care process across the continuum for each condition, cardiac bypass or diabetes or any other condition, then creating a checklist and ensuring adherence and compliance with the process across the care continuum will help in predictable outcomes. A team of process designers to design these processes and then measure them through appropriate metrics will allow optimizing and realizing desired outcomes as well as shared savings. Success will depend on vision, strategy and execution.
At last week’s iHT2 Health Summit at the New York Academy of Medicine, I had the pleasure of introducing Dr. Ben Kanter, chief medical information officer at Palomar Health, California’s largest health district. During his presentation, Dr. Kanter discussed the new $1B, 11-story Palomar Health Medical Center in western Escondido which opened for patient care on August 19, 2012. Called the “Hospital of the Future” by healthcare pundits, the new Palomar facility integrates key technologies, such as EMR, video and collaboration solutions, into an environment that uses nature, light, and outdoor space which work together to promote healing.
During the design phase, Palomar’s leadership team, including Dr. Kanter, worked closely with Cisco on the goal of creating a higher level of mobility and collaboration among clinicians, patients and their families. Cisco technologies currently in use include unified communications (video, WebEx, Wireless IP Phones) along with Unified Computing System, all tied together via a wired and wireless Cisco medical-grade network.
Dr. Ben Kanter, chief medical information officer at Palomar Health:
“The ability Cisco provides to tie everyone in the hospital together – patients, nurses, pharmacists, physicians, infection control, administrative teams -- through a security optimized, mobile and video-enabled environment, will have significant, positive impact across the healthcare continuum. Now patients have greater freedoms within the hospital, without compromising their health, as they are observed both inside and outside of hospital walls. And the ability for our doctors to review patient information from a mobile device, and conference in a nurse and a specialist at the same time to discuss the case, will completely change patient care.”
We invite you to learn more about Palomar Health and to watch a four-minute highlights video about the new medical center.
On September 18, Dr. Ray Costantini, Medical Director and Director of Digital Product Strategy for Providence Health & Services, will discuss the development and implementation of Providence Health eXpress, an innovative, low-cost, video-enabled model of workplace healthcare delivery.
Enabled by Cisco video, Providence Health eXpress:
- Delivers care-at-a-distance in outpatient, direct to consumer situations
- Facilitates remote interactions with licensed, board-certified clinicians
- Provides care for a range of conditions that make up more than 30% of traditional outpatient visits
- Offers clinical services at approximately half of the usual cost
Hear first-hand how your organization can deliver clinical services using secure, fast and convenient video from Cisco.
The Healthcare industry whether payer, provider, pharma or medical device manufacturer finds itself at a very interesting crossroad: the patient is the center of attention and each entity now has an increased focus in achieving outcomes from delivered services.
For providers care coordination of at risk patients in particular accountable care, the threat that re-admissions pose, the need to move non critical patients from ER to more cost effective walk-in facilities; operational efficiencies in specialty access, nursing operations and a flattening of in-patient revenue and the need to build referrals for acute care are driving changes to existing business models.
Pharma is long past blockbuster drugs and the merger and acquisition spree to diversify its drug portfolio and is certainly not immune to an outcome centric approach. Pricing will be determined by outcomes and pricing erosion by generics. Pharma will look at ways and means to reach out to patients to manage adherence, making clinical trials more efficient and simultaneously collaborating with other organizations for research into newer drugs.
Medical device manufacturers are seeing new buying centers in the US as a result of the payment sunshine act and in Europe the muscle of a buying consortium. A significant portion of the portfolio is subject to commoditization from players from China and Turkey amongst others. These manufacturers are taking their case to emerging markets and are looking to services to protect their franchise in mature markets.
Finally payers are reacting to the changes brought in by the Accountable Care Act. The exchanges, (look what happened to the payers before and after the exchange became operational in Massachusetts), 50 million new enrollees will enter the system, some through the exchanges others through Medicaid expansion, limits on administrative expenses, no rescission just to name a few. Payers are experimenting with accountable care models, some consolidating managed care medicaid assets, info-medic technologies or simply acquiring hospitals to become payer providers.
This is a “services” moment for the healthcare industry, service that focuses outcomes.
Healthcare providers are responding to changes in the business needs, analyzing opportunities to drive operational efficiencies as well as delivering care through accountable care models. Accountable care requires access to patients wherever they are in the care continuum- in hospital, extended nursing, skilled nursing, hospice or home. Care needs to reach the patient in any care setting. This shifts the paradigm from patients walking in the door to receive care to care coordination and care being delivered to the patient anywhere. Technologies such as video and telehealth can bring access to the patient in any care setting, allowing borderless delivery of healthcare as a service.
As provider systems vie for patients, patient experience and outcomes will be key differentiators. Smart hospitals with technology can provide the creative edge as well as enable new ways to deliver care. In room videos that provide entertainment, education, physician rounding, EMR access for visiting physicians, patient access to families, surveillance and monitoring, connecting patients to nurses can significantly enhance care, experience and with collaborative multi specialty access from specialists anywhere impact even outcomes. Whether in-patient with acute conditions, outpatients in rehab or with chronic conditions payments will be tied to quality cost and access. As care transitions from one setting to another systems needs to integrate the delivery of healthcare and manage these transitions. Provider systems may see the need to share assets such as EMR, PACs, Quality management, analytics and deliver them as a service to the extended ecosystem.
With access and new business models such as accountable care the nature of healthcare will gradually change from prescription to participation. Care coordinators will draw in physicians and specialist to oversee patient examination. Immersive video and Telehealth will allow a group of specialists to examine and determine a treatment plan.
Collaboration across the care continuum is key and immersive collaboration with high definition video is centric to this change. Video in some form or the other has been around for over 25 years, but it existed in pockets or as some would like to call it science projects it never became mainstream. For collaboration video to become mainstream it has to address business problems and become part of the business architecture, in essence integrate into the IT architecture. Standalone video collaboration systems create islands of automation but do not integrate into hospital business assets the scheduling, EMR, ePACS, billing and quality management systems. Further they lack scalability.
As Healthcare operations integrate care pathways with collaboration and participation, home health, care coordination they need to work with various technologies video, wireless, the need to accommodate smart phone, smartPADs – location, context, security, content creation and distribution, delivery of smart Apps, contact centers and patient relationship management. Healthcare services have to be delivered using the network as a platform. This needs the business architecture to be integrated to the IT architecture and the IT architecture to the Network architecture. The network architecture can be built on a solid medical grade network that is smart, intelligent, extensible, sustainable, flexible, modular, scalable, interoperable, economical and future proof. This is complex and needs a strong architectural foundation with services and applications that use these services.
At the end of the day is there an ROI?
Over the past year we have worked on various models to define a potential ROI for the new healthcare needs. We took a business centric approach looking at the business problem and then identifying value drivers that either brings operational efficiencies or drive new revenue. We focused healthcare segment provider, pharma as well as medical device manufacturers. We built several models some for our customers and validated them:
Accountable care - to what extent can collaboration, video and Telehealth solutions increase cost savings and improve quality metrics to increase the shared savings
Corporate Campus Clinics – how can Telehealth extend the reach to satellite branches, increase uptake through specialties at the main campus and the spoke branches driving benefit both to the Company in increased savings as well as increased penetration and revenue to the medical service provider
What is the business justification for Telehealth and video to assist in reducing readmissions
What is the ROI in moving patients from ER to Urgent care and how could that change be managed
The business justification for using collaboration technologies to increase referrals as well as build specialty networks for operational efficiencies
Is there an ROI in Training and education?
Some of these models looked at problems that were not driven by reimbursement but had enough value drivers to deliver hard savings and justify the investment. Our models show there is a positive ROI in each of these settings.
As any model goes any change is multidimensional. Any new delivery model should become part of business strategy. A structure should be created to implement this new strategy; appropriate architecture approach and platform solutions should drive the strategy, processes need to change to implement the strategy, finally people should be trained with appropriate change management to make this work.
Is there an ROI, yes but the health of that ROI will depend on how well the organization manages this multidimensional change.
Like most families, we are looking forward to the long Labor Day weekend. It will be filled with family, ribs, beer, some yard work, and yes, some Cisco work. And this year we will have a new guest. The latest member of the Barney family, Hayden, arrived just in time to celebrate Labor Day weekend. Although I am sure her mother is not looking back fondly on her recent labors, the rest of the family is. And we are all grateful for the healthy little girl.
But I will have to tear myself away from Hayden, ribs, beer, and yard work for, yes, Cisco work. But that won’t be as painful as it sounds. Thanks to the advanced technologies at Cisco I can work from home. The way I ‘labor’ has definitely changed. I can collaborate over videoconference on my Cisco Telepresence EX-90 with a few of my colleagues to finish up a project while never leaving my house. I live in Ohio, and while my team is located in San Jose, for a few hours on Saturday it will be as if they are all at my house – except they have to get their own beer.
Cisco has changed the way we labor in many important ways, but no more so than when it comes to clinical care. Cisco has created a platform with unified communications and video-based collaboration that is transforming the patient experience and clinical processes by bringing together physicians, specialists, therapists, patients and families together. This collaboration can take place quickly without anyone getting into a car, train, plane or boat. And it becomes stunning when you think about how this can impact the care of a child.
Imagine your child needs cardiac surgery. And he needs a specialist. But that specialist is several hours away from your home. At the Great Ormond Street Hospital in London, Co-Medical Director Professor Martin Elliott, a pediatric cardio-thoracic surgeon uses information and collaboration technologies to improve the quality of care and the experience for the child and its family in a very meaningful way. Listen to Professor Elliott discuss the experience for the medical team, the child, and the family as they prepare the child for surgery.
Collaboration technologies can improve not just the pre-surgical experience, but the follow-up care as well.
For the past 14 years, Dr. Patrick Byrne from Greater Baltimore Medical Center Johns Hopkins University has been making annual trips to countries in the developing world, volunteering his services to correct cleft and lip palate deformities in children. However, in many countries, including Nicaragua, the required post-surgical speech therapy care is simply not available. Using WebEx technology, Dr. Byrne and team can now provide that specialized treatment remotely for the first time ever. Within just three months of speech therapy conducted via WebEx, the doctors saw significant improvement in patients’ speech. The online meeting technology also proved the perfect tool to train local providers on best practices for follow-up procedures. Listen in…