Enabling Data-Centric Healthcare Organizations with the Triple Aim

The healthcare industry is going through immense change. Healthcare expenditures are currently 17% of the overall GDP of the United States and the Institute for Healthcare Improvement (IHI) predicts that number will rise to 20% by 2020[1]. The transition from fee-for-service (sick care) to fee-for-value (well care) has paved the path for the Pioneer ACO programs and larger health system organizations; however, the industry is seeing much smaller organizations beginning to adopt risk-based contracts from both CMS and commercial payers.

There are also major shifts in political pressure to have organizations work with CMS to create new value-based contracts. A major player in the lobbying efforts is the Health Care Transformation Task Force (HCTF), which is comprised of some of the largest payers and providers in the country. Their goal is to have 75% of their respective businesses operating under value-based contracts by 2020.

The HCTF is focusing on the Triple Aim, a term coined by the Institute for Health Improvement (IHI), which is defined as “a framework for optimizing health system performance.”[2] There are three drivers in the Triple Aim approach:

1) Improve the experience of care

2) Improve the health of populations

3) Reduce the per capita costs of healthcare

A focus on these drivers has allowed analytics to gain more visibility in the provider setting. Providers will need personnel that are directly responsible for successfully managing and executing the goals of the Triple Aim. Analytics helps achieve transparency in these organizations for operational excellence; however, a potential risk within these healthcare systems is that analytics initiatives largely originate from IT initiatives when they should be sourced from business units to generate operational value.

Healthcare systems must focus on the overall patient experience in the delivery of care. From improved check-in systems to patient-based portals, engagement and satisfaction analytics must be tracked in order to improve delivery of care.

As the health of populations improve, data availability will be the cornerstone of successfully reducing risk and high-cost claims for healthcare providers. Predictive analytics helps prevent future high-cost episodes and identifies at-risk patients. Similarly, population tracking, both on a geographic and condition level, can prevent high-cost claims and improve the fee-for-value transition.

Enabling data-centric organizations involves great political and cultural pressures, and most initiatives are not successful because of scope and lack of strategy. HIPAA has become an excuse for why these initiatives fail, but it’s more often poor leadership and execution around these efforts that fail.

Data-centric organizations are the future of healthcare. As we transition to fee-for-value, these organizations must take responsibility for what happened and what will happen in the future. The Triple Aim will only be successful if we treat data as a competitive advantage. With Accountable Care Organizations (ACOs), bundled payment structures, and future reimbursement models, value-based care will heavily rely on analytics to be successful.

The Triple Aim is meant to help identify and promote the development of a patient-centric care model. However, the transition to ICD-10 has expanded billing codes to more than 68,000 as compared to only 13,000 with ICD-9. While the change was necessary and mandatory, many providers will have an uphill battle going into to 2016. Challenges with how physicians document pre-existing conditions make it more difficult to accurately predict risk with legitimate claims data. In addition, chronic condition management and grouping of these claims will present additional challenges as healthcare begins to adopt ICD-10. That said, applying the right analytics to ICD-10 billing codes will yield more robust insights that can lead to improved patient care outcomes.

Healthcare reform is strengthened by the adoption of innovative programs, such as accountable care organizations (ACOs), bundled payments, and other innovative reimbursement approaches. Even new models of primary care, such as patient-centered medical homes, are spearheading innovation while improving patient care.

The healthcare industry must determine how patients are identified within the healthcare system to improve the experience of care. Every technology vendor has their proprietary method of identifying or classifying, but a lack of transparency in these systems will actually create disparity in the marketplace. Many “black-box” vendors can actually create friction between business units and IT because of the data “silos” they create, further driving the cultural differences internally.

In conclusion, the Triple Aim will be a cornerstone to embracing analytics and the change to risk-bearing contracts, but this doesn’t come without challenges. Organizations must adopt this patient-centric model to become data-driven organizations. As healthcare transitions to fee-for-value, the Triple Aim will prove to be a valuable compass in improving patient care.

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