Guest Column | January 16, 2020

Consumers Must Be The Focus Of Providers' Value-Based Technology For Managing Risk

By Theresa Hush, Roji Health Intelligence


Providers negotiating risk-based health plan contracts or considering Medicare Value-Based payment options have to decide how they are going to avoid devastating financial losses. As capitation re-emerges as a dominant payment type, providers are using various technologies to supplement their current EHRs and financial systems. Their priorities are on spotting patients and providers who may generate "excessive" costs compared to targets and improve performance.

Most of these systems try to focus on three key solutions to prevent cost spirals:

  • Analytics to identify patients at high risk or frequent utilizers, including predictive cost technology and risk stratification;
  • Population health technology to meet the needs of patients with high cost or risk; and
  • Financial/administrative technology to calculate total costs per patient, estimate and compare episodic costs, review variation, identify critical elements to overruns, and report costs to providers.

Other technologies may be introduced to supplement this foundation, such as for telemedicine, and interoperability with post-acute facilities or regional providers. There are also new to social determinants of health and make population health efforts more effective.

Can Current Technologies Help Reduce Patient Costs In The Long Term?

These technologies are necessary for providers to calculate and manage their costs and have enabled   providers to move forward with Value-Based Healthcare implementation.  But the time-critical question as Value-Based Healthcare evolves into provider financial risk: Can these technologies actually help to reduce patient healthcare costs in the long term? The answer is not so clear.

The problem is that many efficiency gains result in generating only one-time gains in cost performance. More savings must be found each year to override the naturally occurring rise of salaries, new clinical technologies, and investments required to keep pace.

The audience for current Value-Based Healthcare technology is providers. Those providers are conversing with each other and about patients. They're under the assumption is that they're in control of patient costs and medical decisions. While there is a great deal of discussion of patient engagement, most of that engagement is focused on compliance and on responding to providers.

The reality, however, is that provider performance can improve only when consumers change how they approach their health issues, how they make medical decisions, and the information they have available to do so.

Value-Based Technology Investment Must Help Providers Guide Consumers

Controlling costs long term will require that providers guide consumers in all aspects of making medical decisions, with full information on the costs and benefits associated with their options. This will involve both provider- and consumer-facing technology that addresses each aspect of the healthcare decision making process. The basics for consumers include milestones in the process of those decisions:

  1. Patient Designated Support Team Communication Channel. Integrating communications for the provider clinical team, patient and the patient's designated support team members is essential for ensuring that there is an organized medical decision process. Most technology fragments this so that providers have access (on demand) to patient clinical data. But aside from portals that parse limited data to the patient, the patient's support team is excluded and there is little opportunity for dialogue leading to decisions.
  2. Healthcare Education and Literacy Improvement. Most patients are in need of healthcare literacy improvement relevant to their conditions. A precursor to understanding options and making decisions, providers must be able to direct consumers to resources to prepare them with basic understanding of medical terminology, physiology, and pathology associated with their conditions.
  3. Evidence-based Findings for Treatments for Patient Access. Providers will need to establish different processes for patients to iterate their goals and decide treatments based on discussion. Emerging technology is gathering data on the benefit and harms of therapies revealed through clinical trial data. Helping consumers make informed decisions will be a necessary element of managing provider risk.
  4. Transparency of costs associated with projected episodes of care, linked to their eligible benefits. Providers have resisted transparency beyond price lists, but these are of little use to consumers because they don't capture all services in an episode.
  5. Patient-reported outcomes and services feedback. Patient outcomes are usually collected on a short-term basis, while results are usually seen over a much longer time frame. it will be important for providers to go beyond typical survey instruments and really understand what the patient's experience is like, in order to retain the patient.

Providers can improve their cost performance under Value-Based payment models by developing a more collaborative approach to consumers. Consumers are collectively becoming a voice in healthcare, one that providers should recognize as an asset for achieving better outcomes. Technology is a means of cementing that provider-patient collaboration into stronger relationships -- through technology-shared data, information, and communication processes.

About The Author

CEO and Co-founder of Roji Health Intelligence, Theresa Hush is a healthcare strategist and change expert with experience across the healthcare spectrum, including public, nonprofit and private sectors.