Everywhere we turn these days it seems “Big Data” is being touted as a solution for physicians and physician groups who want to participate in Accountable Care Organizations, (ACOs) and/or accountable care-like contracts with payers.
We disagree, and think the accumulated experience about what works and what doesn’t work for care management suggests that a “Small Data” approach might be good enough for many medical groups, while being more immediately implementable and a lot less costly. We’re not convinced, in other words, that the problem for ACOs is a scarcity of data or second rate analytics. Rather, the problem is that we are not taking advantage of, and using more intelligently, the data and analytics already in place, or nearly in place.
For those of you who are interested in the concept of Big Data, Steve Lohr recently wrote a good overview in his column in the New York Times, in which he said:
“Big Data is a shorthand label that typically means applying the tools of artificial intelligence, like machine learning, to vast new troves of data beyond that captured in standard databases. The new data sources include Web-browsing data trails, social network communications, sensor data and surveillance data.”
Applied to health care and ACOs, the proponents of Big Data suggest that some version of IBM’s now-famous Watson, teamed up with arrays of sensors and a very large clinical data repository containing virtually every known fact about all of the patients seen by the medical group, is a needed investment. Of course, many of these data are not currently available in structured, that is computable, format. So one of the costly requirements that Big Data may impose on us results from the need to convert large amounts of unstructured or poorly structured data to structured data. But when that is accomplished, so advocates tell us, Big Data is not only good for quality care, but is “absolutely essential” for attaining the cost efficiency needed by doctors and nurses to have a positive and money-making experience with accountable care shared-savings, gain-share, or risk contracts.
The sharing of patient information in the US is out of whack — we lean far too much toward hoarding information vs. sharing it. While care providers have an explicit duty to protect patient confidentiality and privacy, two things are missing:
- the explicit recognition of a corollary duty to share patient information with other providers when doing so is the patient’s interests, and
- a recognition that there is potential tension between the duty to protect patient confidentiality/privacy and the duty to share — with minimal guidance on how to resolve the tension.
In this essay we’ll discuss:
1. A recent recognition in the UK
2. The need for an explicit duty to share patient information in the US
A recent analysis of the ACO market by Oliver Wyman market suggests we’re well on our way toward being “there.”
My personal take on this report:
Provocative, fresh, thoughtful, well reasoned, expansive — albeit a bit of a stretch
However, I suspect many others will describe it as:
Speculative, harebrained, unsupported, overly extrapolative, out-to-lunch, wishful to the point of being woo woo.
So now that I hopefully have your attention, what’s this report all about? In a nutshell:
The healthcare world has only gotten serious about accountable care organizations in the past two years, but it is already clear that they are well positioned to provide a serious competitive threat to traditional fee-for-service medicine. In “The ACO Surprise,” our analysis finds that 25 to 31 million Americans already receive their care through ACOs—and roughly 45 percent of the population live in regions served by at least one ACO.
Let’s dig in to the report. In this blog post, I’ll summarize their math, surface their critical assumptions and observations, and comment on their reasoning. I’ve indented direct quotations from the report.
While I don’t agree with all of Oliver Wyman’s math and assumptions, I applaud them for the process they have gone through. Please take my commentary as “quibbling at the edges” and that overall I’m on board with their methodology and conclusions.
From reading recent headlines, one might easily get the impression that hospitals are resistant — or at least ambivalent — in their pursuit and adoption of accountable care initiatives.
Are Hospitals Dragging their Feet on Accountable Care?
Commonwealth Fund: “only 13 percent of hospital respondents reported participating in an ACO or planning to participate within a year”
KPMG Survey: “(only) 27 percent of [health system] respondents said current business models were either not very or not at all sustainable over the next five years”
Health Affairs: “Medicare’s New Hospital Value-Based Purchasing Program Is Likely To Have Only A Small Impact On Hospital Payments”
The Bigger Picture
Do hospitals today perceive their current business model on the metaphorical “burning platform” — when the status quo is no longer an alternative?
The answer from the headlines above might suggest “no”, but I believe the correct answer is “not yet, but it’s inevitable”. Hospitals are feeling the heat, but it’s just not yet hot enough to jump off the platform and abandon existing business models.
Gregg Masters reports on a recent Kaiser Health News article: Hospitals Look to Become Insurers, As Well as Providers of Care”.
This is the dumbest idea I’ve heard since “I’m going to invest all my money in Facebook’s IPO and get rich!”
Here are six reasons why:
1) You’re too late. Health insurance was an attractive and profitable business in the 00s, but after passage of the Accountable Care Act it’s been commoditized.
First, the health plan business model of the past decade is dead. That model was — “Avoid and shed risk” — or more simply, avoid insuring people who are already sick (preexisting conditions) and get rid of people who become sick (rescissions). Under the ACA, health insurers must take all comers and they can rescind policies only for fraud or intentional misrepresentation.
Second, the ACA institutes medical loss ratio restrictions on health insurers. Depending the the type of plan, insurers now must spend at least 80-85% of premium dollars on paying medical claims; if they spend less, they must return these “excess profits” as rebates to customers. As a result, health insurance has become a highly regulated quasi public utility.
This is why you see health plan CEOs like Mark Bertolini of Aetna declaring “Health insurers face extinction”. The old health insurance model is on a burning platform, and health plans are reformulating themselves as companies involved in health IT, analytics, data mining, etc.
2) You have bigger fish to fry. Focus on developing accountable care capabilities. The AHA estimated that hospitals will need to spend $11-25 million to develop an ACO. Get going.
A study released last week by the Massachusetts Attorney Generalcontains surprising data to challenge two commonly held ACO (accountable care organization) ”Field of Dreams” assumptions. These assumptions relate to patient ”leakage” — out-of-network patient care and referrals.
1) Hospital administrators assume that tighter physician-hospital integration (e.g., through employment of physicians) will result in ”captive referrals” by physicians back to the mother-ship hospital.
2) Medicare administrators are assuming that Medicare Shared Savings ACOs will be able to coordinate patient care even without limitations on patients’ choice to go to providers outside of the ACO provider network.
Here’s the data that challenges the validity of BOTH of these assumptions:
Particularly for provider systems where hospitals and physicians are jointly at risk for the quality and cost of patients’ care, and have worked together to coordinate and improve care, we would expect to see physicians referring to their partner hospital more often. However, for the two physician-hospital provider systems in Massachusetts with the most years of experience managing referrals for HMO/POS patients under a global payment, one health insurer’s 2009 referral data shows that only 35-45% of adult inpatient care, as measured by revenue, goes to the partner hospital. That percentage can be even lower for providers with little to no experience managing where their patients receive specialist/hospital care, or under plan designs that do not require referrals. [emphasis added]
Unlike some of my colleagues, I’m not losing ANY sleep over whether personal health record (PHR) systems ultimately will be adopted and used by patients.
In my mind, the issue isn’t WHETHER, but WHEN.
Yes, I know that adoption has lagged and that surveys suggest 7% or less of the U.S. population has used a PHR.
Stay with me on this one for a minute. You’d have to have two underlying beliefs to conclude that PHR systems won’t eventually emerge:
- That health record data will persist in non-electronic formats, i.e., paper
- That people won’t have interest in accessing or using their health record data
Please think about this a moment. If you truly believe PHRs will continue to remain a non-starter, then you MUST logically believe in one or both of these assumptions.Continue reading…
My guess is you’ve probably never asked yourself this question. A quick preview:
- Technical barriers aren’t the limiting factors to Facebook becoming a care coordination platform.
- Facebook’s company DNA won’t play well in health care.
- Could Facebook become the care coordination platform of the future? If not Facebook, then what?
1) Technical barriers aren’t the limiting factors to Facebook as a care coordination platform.
Can you imagine Facebook as a care coordination platform? I don’t think it’s much of a stretch. Facebook already has 650 million people on its network with a myriad of tools that allow for one-to-one or group interactions.
What would it take to make Facebook a viable care coordination platform?
- More servers to handle the volume — not a problem
- Specialized applications suited for health care conditions — not a problem
- Privacy settings that made people comfortable — more on this later
- A mechanism to identify and connect the members of YOUR care team — really tough, BUT this is NOT a technological problem, but a health system one
Suppose you are a 55–year-old woman who is a brittle diabetic. Your care team might include a family physician, an endocrinologist, a registered dietitian, a diabetic nurse, a ophthalmologist, a podiatrist, a psychologist, and others. Ideally you’d have one care plan that coordinates the care among members of the team, including you.Continue reading…
Regular readers know that I find Professor Clay Christen’s theory of disruptive innovation to be a useful lens to explain industry evolution. Let’s look at two recent health IT initiatives and see why one is working and the other is stalled.
Characterizing the Direct Project — why it’s working:
A low-end industry disruption. The Direct Project takes transactions that are routine but inefficient — fax, telephone, mail exchanges between health care providers — and specifies standardized, Internet based technologies to conduct them electronically.
Incremental change — a few specified transactions.
Bottom up — ONC hired a capable project manager (Arien Malec) who choreographed a small team of volunteers working under short deadlines.
Implementing “better, faster, cheaper” technology on the fly (i.e., Internet transactions replace fax, phone).
By VINCE KURAITIS
Health care lobbyists and advocates are bracing for six pages of the health care reform law to explode into more than 1,000 pages of federal regulations when the Department of Health and Human Services releases its long-delayed accountable care organization rules this week. Politico
What should you be looking for as you snuggle by the fireplace this weekend reading the draft ACO regs?
Rob Lazerow writes a helpful article listing 5 Things to Watch in the Medicare Shared Savings Program Proposed Rule. His list of five key design issues includes:
- How will patients be assigned to ACOs?
- To what cost benchmark will ACOs be compared?
- How will bonuses be calculated and paid?
- For which quality metrics will ACOs be responsible?
- What is the application process?
I’d like to add a sixth item — which actually would be #1 on my list.
As I’ve previously written, IMHO the central issue around ACOs is:
Are (hospitals and doctors) viewing ACOs as a way to truly develop patient centric, collaborative care or as a means toward consolidating market power against payers? We really don’t know.Continue reading…