Guest Column | March 24, 2016

Making An Impact: How Evidence-Based Guidelines Drive Value-Based Success

Accountable Care

By Joe Guerriero, Senior Vice President of MDGuidelines, Reed Group

By 2020, accountable care organizations (ACOs) are expected to provide care for at least 105 million patients, up from 23 million in December 2015. With ACOs assuming more responsibility for the quality and cost of care, this rapid patient growth is driving the need for new, more intelligent clinical decision support tools at the point of care. These tools can help ACOs deliver consistent, evidence-based care so patients can return to health safely and quickly.

A large body of scientific evidence shows returning individuals to active living provides significant health benefits. For example, activity-based rehabilitation and returning to activity are shown to be therapeutic for the health and well-being for patients. Other studies show returning patients to active living reduces the risk of long-term inactivity and is also associated with lower mortality rates. In addition, prompt recovery times can reduce spending for provider organizations, payers, employers, and patients. Individual providers and care teams, however, currently lack reliable decision support tools at the point of care to enable personalized and informed clinical decision making.

Having this insight, as well as the ability to measure performance and adherence to evidence-based protocols, is critical for ACOs and other healthcare organizations participating in value-based contracts. With trustworthy guidance, providers can improve quality metrics and patient outcomes while driving out inconsistencies and waste.

Providers Face Care Quality And Financial Pressures

Evidence-based care is not a new concept, but many providers lack easy access to clinical guidelines at the point of care. When providers must rely on training and experience alone to determine optimal treatments, the result is often inconsistent or duplicative care. Having access to evidence-based guidelines during patient encounters can help providers reduce unnecessary care, improve outcomes and maximize reimbursement. In fact, a recent study revealed that 30 percent of all Medicare spending could be avoided without worsening health outcomes.

Decision support tools can also help providers form accurate estimates of patient recovery times for injury and illness. When providers have the ability to combine personalization with optimum recovery timeframes at the point of care, it is possible to facilitate an informed dialogue between doctor and patient. Involving the patient in decision making has been associated with improving patient engagement and outcomes. Engagement is key in managing ongoing chronic conditions that linger after an acute illness or injury has healed.

Additionally, when a provider sets recovery expectations, the patient is able to take a more active role in their return to health. Ensuring optimal communication between providers and patients can positively impact the patient responses to the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey as well. These surveys comprise 25 percent of the score that the Centers for Medicare and Medicaid Services uses to calculate an organization’s incentive payment under the Hospital Value-Based Purchasing System.

Point-Of-Care Decision Support Tools Fill Informational Gaps

With evidence-based clinical guidelines at the point of care, ACOs can help ensure providers are consistently following the most effective protocols. When these guidelines are supplemented with recovery duration tables, providers have an objective and consistent basis to form accurate estimates of how long it will take a patient to return to health.

For a more personalized estimate, predictive modeling capabilities integrated with other decision support tools allow providers to factor in unique patient characteristics, including any other existing conditions, to create a more precise duration estimate. From there, treatment plans can be effectively shared with care teams throughout the continuum of care. Resources can be coordinated appropriately toward the goal of returning patients to wellness as efficiently as possible, while managing setbacks if they arise.

If the point-of-care tools are built on a robust analytic framework, ACOs can then measure clinical performance against normative and optimal benchmarks at the diagnostic group or code level. Informed by millions of cases, these normative benchmarks can help guide an organization’s process improvement efforts by giving them the ability to benchmark and compare their performance against their peers. Organizations that perform this type of analysis may be pleasantly surprised how often their patients return to full activity faster than industry benchmarks.

Measuring Clinical And Financial Performance

Analytics can be also used to measure the effectiveness of point-of-care guidelines and predictive tools. For example, reporting can reveal where best practices for treatment planning and management need to be implemented, where treatment inconsistencies linger, and which higher-risk patients require proactive interventions and management.

Organizations that demonstrate how the use of proven, evidence-based clinical guidelines, duration tables and analytics helps individuals return to full health and activity faster will have a strong differentiator in their respective market. This differentiator can help attract new agreements with third-party payers or self-funded employer health plans, ultimately allowing ACOs to expand market share, generate more revenue and strengthen the bottom line.

Managing Financial Risk Requires Better Information

Managing financial risk is a new concept for most provider organizations, but it is essential for success in an increasingly value-based world. To effectively manage risk, providers need evidence-based information and tools at their fingertips to help improve outcomes and avoid unnecessary and costly variations in care.

Although most physicians, outside of a few specialties, are not trained to determine the length of time it may take for a patient to heal and safely return to full activity, this guidance will become crucial to maintain an ACO’s clinical and financial performance. For example, forming accurate estimates can help improve outcomes and reduce excessive resource utilization, such as over-testing or performing ineffective procedures and treatments.

By leveraging the right combination of evidence-based guidelines and analytics, ACOs and other risk-bearing healthcare organizations can effectively monitor clinical performance and provider behaviors. With the insights these tools deliver, organizations can then offer education and training to help providers understand and adhere to evidence-based protocols and actively engage patients in their recoveries.

Most importantly, decision support tools and analytics can help individuals return to full activity faster, which benefits providers, payers, employers, and patients.

About The Author

Joe Guerriero is Senior Vice President of MDGuidelines at Reed Group.