To Share Savings, Providers Must Share Risk

In our April Intelligence Report, the top challenge cited by leaders in pursuing a collaborative care model is "concerns about the ultimate cost savings." Members cited coding discrepancies, budget cuts, and convincing physicians to share the risks as barriers to incorporating a collaborative care model.

What do you see as the path to ensure cost savings in a collaborative care model, and what can leaders do to facilitate that?

Robert Ross, MD
Medical Director of Community Health Strategy
St. Charles Health System, St. Charles Medical Group
Bend, Ore.

On behavioral health: We have four clinics that are Tier 3 medical homes and in three of them we have fulltime behavioral health folks. For example, if a physician or actually any member of the team identifies a patient as being depressed they can get help not just in terms of medication but also using both psychotherapy or some type behavioral therapy and medications, which results in better outcomes for patients.

On coordinating payments: One of the problems we encounter is that you have to divide up the billing and costs for the separate services. Ultimately to have the many services, not just behavioral health but other things like pharmacy services, you could name a billion things, especially with people who have difficulty with access, so combining those and paying for them with some sort of global fee, probably capitation, would make it easier for everyone concerned and not just physicians. It eliminates costs for insurers as well in terms of verifying that services were delivered. Ultimately that is where we are heading, but that is a guess.

On coding shortcomings: There is a huge unexplored area of what is not coded and what things that patients have or experience that potentially are in the notes but not discerned by payers. The data we mine is determined by the provider codes and that is not a particularly accurate way of getting at people's problems because you code for what you are paid for and not necessarily for all the problems that are contained in a patient visit. It's a very complex problem.

Andre Boyd
COO
TriStar Greenview Regional Hospital
Bowling Green, Ky.

We are starting the whole process of clinical integration through our lead CMO for our division. We are garnering support from each of the physician practices in each of our cities that we provide services for.

With that, will have a true infrastructure to help manage the data collection as well as help manage the partnerships and the follow-up care that we need to do with our physicians.

In my organization typically collaborative care means partnering with our providers and other ancillary organizations to provide the best care possible for our patients. The biggest issue is getting doctors to understand that it makes a difference. When we talk about partnering to share risk it means we are taking an opportunity to move the quality agenda forward for our organization and for their patient population but doing it where if you are able to achieve this outcome, then you get incentivized.

It's also making sure that we are reducing or eliminating as much variation in clinical care as possible, and to do that we have to partner with doctors and get on the same path to make sure we understand that here at Greenview we do a process for congestive heart failure. Maybe that same process will work collaboratively at another hospital we own. So let's make sure we are standardizing our policies and programs appropriately."

Maureen Swick, RN, PhD
Senior Vice President, Chief Nurse Executive
Inova Health System
Falls Church, Va.

At Inova we have utilized Lean teams looking at our care delivery model, ensuring that the right person is doing the right job with regard to roles and responsibilities. We have also implemented multidisciplinary rounds. It's really about team. From the efficiency and patient and family engagement perspective, that helps facilitate a more efficient process by engaging the patient and the family up front with the plan of care for the patient. The inpatient coordination becomes much more efficient for the patient and the family.

The amount of rework, phone calls, delays, testing, and coordination is huge when that is not done in an integrated and collaborative way right up front.

When we talk about the team with the physicians and everyone working collaboratively on the plan of care that helps with the length of stay. That is how we are monitoring whether or not we are successful.

From a cost savings perspective, when we looked at our care delivery model we were heavy with RNs and now we have implemented techs because we used our Lean experts and looked at having nurses function to their full license and training. If they had anything that did not require their license, we developed a role for the clinical technicians. That shift right there from a mostly RN model to a mixed model is a huge cost savings from a labor perspective.

Thomas G. Lundquist, MD
President and CEO, AnewCare Collaborative,
Chief Clinical Integration Officer, Integrated Solutions Health Network
Johnson City, Tenn.

We are an ACO that was formed in the middle of last year, a Medicare shared-savings program. But we also have commercial lives that are starting to access our narrow network under the ACO.

A big challenge is to find the right partners and the finances that work, but we are marching down that path slowly but surely. Another challenge is devoting the resources to build effective teams within the physicians' offices that are participating in the integrated care model. There is a need to, especially on the primary care front, bolster the ranks of care coordination. That could be nurses or social workers or even public health student graduates who understand population health dynamics.

Not only do you need the people, but you need the right tools to be effective and reach out to patients in a consistent and coordinated manner that can be documented in terms of how they do their work. You have to make that investment in people and process tools or you will come up with a lack of a return on investment.

We are fighting all the pressures on healthcare in terms of budget cuts and its impacts of our organizations and how they are funded. That is the goal, to put the people and the teams together and design the processes for putting the people in place who can then reach out to the patients on behalf of the physicians and work with the physician in a team atmosphere.