Webinar – Telehealth 2018: Healthcare Beyond the Exam Room

In this webinar, Chilmark President John Moore presents key findings from our report, Telehealth 2018: Vendor Assessment and Market Impact. Afterward, he discusses broader telehealth opportunities and challenges with special guests Ann Mond Johnson (CEO of the American Telemedicine Association) and Dr. Brian Zack (Medical Director of Telehealth Services at University Hospitals Cleveland).

Key topics addressed:

  • Drivers and challenges to telehealth adoption
  • Greatest opportunities for telehealth to impact care delivery and outcomes
  • Current market segments
  • Potential disruptions to the telehealth market

You can also read some of the report’s findings in our blog post on provider adoption of telehealth.

To access the slides, please enter your email address in the video form or at the bottom of the page. To learn more about the report or to purchase it, please click here.



Stay up to the minute.

Did You Know?

Revisiting Our 2018 Predictions

As is our custom here, we like to look back on our predictions for the closing year and see just how well we did. Some years we do amazingly well, others we over-reach and miss on quite a few. For 2018, we got seven of our 13 predictions spot-on, two were mixed results and four predictions failed to materialize. If we were a batter in the MLB we would have gotten the MVP award with a .538 batting average. But we are not and have to accept that some years our prediction average may hover just above the midpoint as it did this year.

Stay tuned, 2019 predictions will be released in about one week and it is our hope that they will inspire both rumination and conversation.

(Note: the bigger and plain text are the original predictions we made in 2017, while the italic text is our review of 2018). 

Merger & acquisition activity continues; Humana or Cigna acquired.

Major mergers and acquisitions that mark the end of 2017 (CVS-Aetna, Dignity Health-CHI and rumored Ascension-Providence) will spill over into 2018. Both Humana and Cigna will be in play, and one of them will be acquired or merged in 2018.

MISS – neither happened. However, Cigna did pick-up PBM service Express Scripts and rumors continue to swirl about a possible Humana-Walmart deal or more recently, even a Walgreens-Humana deal.

 

Retail health clinics grow rapidly, accounting for 5 percent of primary care encounters.

Hot on the health heels of CVS’ acquisition of Aetna, growth in retail health reignites, albeit off a low overall footprint. By end of 2018, retail health clinic locations will exceed 3,000 and account for ~5% of all primary care encounters; up from 1,800 and ~2%, respectively, in 2015.

MISS – Modest growth in 2018 for retail health clinics with an estimate of around ~2,100 by year’s end. Telehealth, which is seeing rapid growth and on-site clinics may be partially to blame.

 

Apple buys a telehealth vendor.

In a bid to one-up Samsung’s partnership with American Well, and in a bid to establish itself as the first tech giant to disrupt healthcare delivery, Apple will acquire a DTC telehealth vendor in 2018.

MISS – Apple continues to work on the periphery of care with a focus on driving adoption of its Health Records service in the near-term with a long-term goal of patient-directed and curated longitudinal health records.

 

Sixty percent of ACOs struggle to break even.

Despite investments in population health management (PHM) solutions, payers still struggle with legacy back-end systems that hinder timely delivery of actionable claims data to provider organizations. The best intentions for value-based care will flounder and 60% of ACOs will struggle to break even. ACO formation will continue to grow, albeit more slowly, to mid-single digits in 2018 to just under 1,100 nationwide (up from 923 as of March 2017).

HIT – MSSP performance data showed only 34% earned shared savings in 2017 (up from 31% in 2016) and by year’s end it is estimated there will be ~1,025 ACOs in operation.

 

Every major EHR vendor delivers some level of FHIR support, but write access has to wait until 2019.

While some of the major EHR vendors have announced support for write access sometime this year and will definitely deliver this support to their most sophisticated customers, broad-based use of write APIs will happen after 2018. HCOs will be wary about willy-nilly changes to the patient record until they see how the pioneers fare.

HIT FHIR-based read APIs are available from all of the major EHR vendors. Write APIs are still hard to find. To be fair, HCOs as a group are not loudly demanding write APIs.

 

Cloud deployment chips away at on-premises and vendor-hosted analytics.

True cloud-based deployments from name brand vendors such as AWS and Azure are in the minority today. But their price-performance advantages are undeniable to HIT vendors. Cerner will begin to incent its HealtheIntent customers to cloud host on AWS. Even Epic will dip its toes in the public cloud sometime in 2018, probably with some combination of Healthy Planet, Caboodle, and/or Kit.

HIT – adoption of cloud computing platforms is accelerating quickly across the healthcare landscape for virtually all applications. Cloud-hosted analytics is seeing particularly robust growth.

 

True condition management remains outside providers’ orbit.

Providers will continue to lag behind payers and self-insured employers in adopting condition management solutions. There are two key reasons why: In particular, CMS’s reluctance to reimburse virtual Diabetes Prevention Programs, and in general, the less than 5% uptake for the CMS chronic care management billing code. In doing so, providers risk further isolation from value-based efforts to improve outcomes while controlling costs.

HIT – Awareness of the CCM billing code (CPT code 99490) remains moderate among providers and adoption is still estimated at a paltry less than 15%.

 

Mobile-first becomes the dominant platform for over 75% of care management solutions.

Mobile accessibility is critical for dynamic care management, especially across the ambulatory sector. More than 75% of provider-focused care management vendors will have an integrated, proprietary mobile application for patients and caregivers by end of 2018. These mobile-enabled solutions will also facilitate collection of patient-reported outcome measures, with 50% of solutions offering this capability in 2018.

MIXED – While the majority of provider-focused care management vendors do have an integrated mobile application (proprietary or partnership), collecting PROMs is still a functionality that remains limited through an integrated mobile solution.

 

Solutions continue to document SDoH but don’t yet account for them.

A wide range of engagement, PHM, EHR, and care management solutions will make progress on documenting social determinants of health, but no more than 15% of solutions in 2018 will be able to automatically alter care plan interventions based on SDoH in 2018.

HIT – despite all the hoopla in the market about the need to address SDoH in care delivery, little has been done to date to directly affect dynamic care plans.

 

ONC defines enforcement rules for “data blocking,” but potential fines do little to change business dynamics that inhibit data liquidity.

The hard, iron core of this issue is uncertainty about its real impact. No one knows what percentage of patients or encounters are impacted when available data is rendered unavailable – intentionally or unintentionally. Data blocking definitely happens but most HCOs will rightly wonder about the federal government’s willingness to go after the blockers. The Office of the National Coordinator might actually make some rules, but there will be zero enforcement in 2018.

MIXED – Last December we said, “The hard iron core of this issue is uncertainty about its real impact.” Still true. Supposedly, rulemaking on information blocking is complete but held up in the OMB. The current administration does not believe in regulation. So “data blocking” may be defined but there was and will be no enforcement or fines this year.

 

PHM solution market sees modest growth of 5-7%.

Providers will pull back on aggressive plans to broadly adopt and deploy PHM solution suites, leading to lackluster growth in the PHM market of 5% to 7% in 2018. Instead, the focus will be on more narrow, specific, business-driven use cases, such as standing up an ACO. In response, provider-centric vendors will pivot to the payer market, which has a ready appetite for PHM solutions, especially those with robust clinical data management capabilities.

HIT – PHM remains a challenging market from both payment (at-risk value-based care still represents less than 5% of payments nationwide) and value (lack of clear metrics for return on investment) perspectives. All PHM vendors are now pursuing opportunities in the payer market, including EHR vendors.

 

In-workflow care gap reminders replace reports and dashboards as the primary way to help clinicians meet quality and utilization goals.

This is a case where the threat of alert fatigue is preferable to the reality of report fatigue. Gaps are important, and most clinicians want to address them, but not at the cost of voluminous dashboards or reports. A single care gap that is obvious to the clinician opening a chart is worth a thousand reports or dashboards. By the end of 2018, reports and dashboards will no longer be delivered to front-line clinicians except upon request.

MISS – Reports and dashboards are alive and well across the industry and remain the primary way to inform front-line clinicians about care gaps.

 

At least two dozen companies gain FDA-approval of products using machine learning in clinical decision support, up from half a dozen in 2017.

Arterys, Quantitative Insights, Butterfly Network, Zebra Medical Vision, EnsoData, and iCAD all received FDA approval for their AI-based solutions in 2017. This is just the start of AI’s future impact in radiology. Pioneer approvals in 2017 — such as Quantitative Insights’ QuantX Advanced breast CADx software and Arterys’s medical imaging platform — will be joined by many more in 2018 as vendors look to leverage the powerful abilities of AI/ML to reduce labor costs and improve outcomes dependent on digital image analysis.

HIT – With about a month left in 2018 the count of FDA approved algorithms year to date is approaching 30 and could potentially hit three dozen by year end. This is a significant ramp up in the regulatory pipeline, but more is needed in the way of clear guidance on how they plan to review continuously learning systems and best practices for leveraging real-world evidence in algorithm training and validation.

 

What do you think of 2018 for health IT?

How will Proposed Changes to CMS Telehealth Reimbursement Affect Adoption?

Key Takeaways

  • CMS-proposed rule changes extend Medicare Advantage and Part D plan coverage for telehealth services starting in 2020
  • Proposal includes enhancements to the Star Ratings methodology, which include updating the cut-point determination methodology as well as adjustments for Star Ratings in times of uncertainty, such as hurricanes.
  • Under the proposed changes, starting in 2019 in Medicare FFS, CMS will reimburse for virtual check-ins, evaluation of patient submitted photos, and prolonged preventive services regardless of patient location and care facility.

What the Rule Changes Mean

doctor cares for medicare patient via telehealthOn Friday, October 26, the Centers for Medicare and Medicaid Services (CMS) announced several rule changes that affect how telehealth services will be covered under Medicare Advantage (MA) and the Medicare prescription drug program (Part D). These changes are in direct response to the Bipartisan Budget Act of 2018, which eliminated historical restrictions on telehealth reimbursement, and are intended to “improve quality of care and provide more plan choices for MA and Part D enrollees.”

Also included in the proposed rule changes are adjustments to methodologies and processes that should improve access to care, as well as recover funds from payments improperly applied to insurance companies. We view this as a positive development, especially as it relates to current and projected physician shortages. Greater reimbursement should allow for providing some basic services through telehealth applications, it is going to equip providers with the ability to “do more with less.”

Our recent report, Telehealth Beyond the Hospital, provides a detailed analysis of the telehealth market as a whole, but we felt it prudent to prepare a supplemental post to give a brief examination of how these rule changes could potentially impact the provision of healthcare services.

Easing Reimbursement via Classification

Telehealth services have previously seen limited implementation by MA plans because they have been traditionally classified as services covered by “supplementary medical insurance.” These new rule changes shift the classification of telehealth services to the “basic benefits” category. We have witnessed lagging adoption rates of telehealth technologies over the last several years, and view the inclusion of these services into the basic benefits category as a necessary step to increase their rate of use.

CMS expects that the inclusion of telehealth services in the basic benefits category will spur more MA plans to offer these benefits beginning in 2020, and increase their support of these services in subsequent years. This isn’t happening in a vacuum, and is in line with the broader push to promote telehealth services as viable alternatives and supplements to traditional care options. The move towards parity between physical visits and telehealth services has shown to increase reliance on telehealth services before: Michigan has seen a “77.5% increase in Telemedicine encounters after supporting service parity in telemedicine.”

This isn’t happening in a vacuum and is in line with the broader push to promote telehealth services as viable alternatives and supplements to traditional care options.

Driving Near-Term Adoption: Patient Satisfaction and Ease of Access

Recent surveys have shown that patients are growing more and more amenable to remote care options, especially if it reduces their out-of-pocket costs. The opportunity cost of non-reimbursed care is one of the primary barriers to provider adoption of telehealth services, and by removing this barrier we will hopefully see further alignment between providers and patients on this issue.

We see this alignment as a part of the greater industry shift towards value-based care (VBC). As we noted in our Patient Relationship Management (PRM) Market Scan Report, engagement was one of the areas where adoption of these new technologies for VBC was exceeding expectations. Increased reimbursement for telehealth should continue this positive trend and hopefully allow for the realization of some PRM benefits.

We predict that the CMS rule changes will encourage diversified managed care organizations (MCOs) to expand their current commercial telehealth contracts to their MA business and also potentially drive the adoption of telehealth offerings among that trend.

Impact on Providers and Vendors

These new rule changes have a large potential upside for all players in the telehealth market, but it is important to note that telehealth adoption has been incremental over the last several years and there is no reason to predict a stark diversion from that trend.

We predict that the CMS rule changes will encourage diversified managed care organizations (MCOs) to expand their current commercial telehealth contracts to their MA business and also potentially drive the adoption of telehealth offerings among that trend.

Vendors looking to capitalize on this incremental market growth are going to have to navigate the differing needs of commercial and Medicare providers. For commercial providers, telehealth is seen primarily as a cost-savings and efficiency tool. For Medicare providers, they are looking most closely at telehealth as a way to promote post-acute care management and patient engagement. To effectively sell to Medicare providers, vendors are going to have to tailor their tools and pitches to hit on the appropriate pain points.

Conclusion

As the costs of chronic condition management skyrocket, looking for innovative telehealth solutions is of paramount importance.  Reclassification as basic services and simplification of the reimbursement process will certainly help vendors supplying these solutions overcome potential buyer uncertainty on the ROI of their products.

The most important takeaway from these rule changes from an HCO perspective is that the future of value-based care is arriving quickly. HCOs need to prepare for this future by refreshing their care delivery strategies, especially as it relates to primary care. The primary care environment is changing, and HCOs need to closely examine what they need to provide in terms of physical locations, providers, and services for their patient populations. They then need to craft strategies to meet these evolving requirements.

How Healthcare Leaders Adapt to the Evolving Front Door to Care

by Brian Eastwood and Paul Nardone

When today’s healthcare consumers have questions about their health, they are no longer limited to phone calls to the doctor’s office or visits to the emergency room. Technology has enabled and supported the creation of numerous new “front doors to care” – including but not limited to telehealth, chatbots, digital therapeutics, retail health, urgent care, and community-based clinics – that threaten to disrupt traditional care delivery models.

We recently interviewed two leaders at organizations leveraging telehealth to meet patients where they are and complement existing clinical workflows:

  • Joseph Brennan, Senior Director, MedNow at Spectrum Health
  • Chris Johnson, Vice President and General Manager, Landmark Health

Excerpts of these interviews appear below. They have been edited for clarity.

Briefly describe the solution or service you offer and how it opens a new front door to care for patients.

Brennan: MedNow is Spectrum Health’s direct to consumer (DTC) telehealth program. It has been in place for four years. It lets patients see a provider on their device for low acuity primary care conditions. Custom-building a mobile app that integrates with the EHR enabled us to enhance the patient experience and complement all of the other digital tools that Spectrum Health offers.

Johnson: We describe Landmark Health as a leading-risk medical group. We contract primarily with payers but can also contract with anyone who takes on risk. We focus exclusively on patients with 6 or more chronic conditions and are available to them 24/7/365 telephonically or in their home. We have physician leaders who take care of patients and are supported by interdisciplinary teams: Case management, behavioral health, pharmacists, dietitians, social worker, and non-clinical healthcare ambassadors who help build relationships with patients in between clinical visits and help them with education.

Was the motivation to adopt a solution that would open a new “front door to care” driven by clinical, financial, or operational needs?

Brennan: All of the above. The primary driver for us creating a great patient experience is that it is quickly becoming an expectation of patients who want convenient access to care. In addition, as healthcare transitions to value-based care (VBC), cost reduction is paramount.

Johnson: The hospital business model isn’t designed to provide longitudinal care of patients with complex conditions. We designed a model from the group up that could provide care for patients when they need it (24/7) and where they need it – in the comfort of their home. Patients with complex chronic conditions have a generally steady high medical spend year-over-year, so intensive longitudinal models to improve their long-term health work well. There are also psychosocial elements, including depression, dementia as well as addiction. This can be impacted by the interdisciplinary approach – specifically the incorporation social work and behavioral health – of our clinical model.

Hospitals state outwardly that they don’t want inappropriate hospitalizations. We are not taking away their core business treating patients in need of acute care.

How did you make the case for implementing a front door to care that has the potential to adversely impact another part of the business?

Brennan: Throughout development of our program, we were very conscious of cannibalization. Telehealth takes visits out of the emergency department and replaces it with something much less expensive. In preparing our health system for the future, we would rather get ahead of reducing healthcare costs than react to it. We need competencies in virtual care for the future and chose to build it now, rather than trying to catch up later.

Johnson: Hospitals state outwardly that they don’t want inappropriate hospitalizations. If there’s a readmission, they don’t get paid the second time, so we partner with them on discharge planning. Conceptually, they’re aligned. We are not taking away their core business treating patients in need of acute care.

Which stakeholders did you need to engage when first making your pitch – and who was the hardest to convince?

Brennan: We emphasized both clinical and operational benefits. Many health systems focus on one or the other; our strategy was to focus on both. The primary resistance came from physicians who were not convinced this was an appropriate standard of care. Four years into our telehealth journey, some physicians still don’t believe that virtual care is part of the future. We can attribute much of our success to the buy-in and support of executive leadership.

Johnson: We’re something that not a lot of people have seen before. It takes a bit of time to explain who we are and assuage fears that we will be competing for members with primary care physicians. We’re not a PCP, and we encourage strong relationships with a PCP. When we enter a market, PCP visits stay the same, or even increase a little bit. Once PCPs see the effects, they realize it’s really only a small number of their panel – and it’s usually the ones they find the hardest to manage, who have a lot of barriers to care.

When we are measuring the growth of our encounters, we are thinking of it as a convenient front door to the system, so it makes sense to measure how many people come through that door. Other important metrics include new patients to the system, cost savings to payers, avoided ED and Urgent Care visits, and patient miles saved.

What KPIs or other metrics are most important to measuring the success of your front door to care initiative? Are you focused on raising awareness, boosting business, or adding revenue?

Brennan: For us, it’s the number of encounters. With virtual care, the only way to scale is through increasing volume. When we are measuring the growth of our encounters, we are thinking of it as a convenient front door to the system, so it makes sense to measure how many people come through that door. Other important metrics include new patients to the system, cost savings to payers, avoided Emergency Department and Urgent Care visits, and patient miles saved.

Johnson: Our service significantly reduces the medical expense reimbursement for a patient and improves the medical loss ratio for that covered population – from north of 100% to something quite profitable. Health plans can take a segment of members that used to be challenging and bring it in line with the rest of their book of business. This allows our plan partners to keep premiums lows and invest in additional services for their members.

How does your new front door to care reduce the friction that often makes it difficult for patients to seek the care they need?

Brennan: First and foremost, it’s access. Our average wait time for a visit is 12 minutes and we are available 24/7. MedNow sees patients regardless of having a relationship with a Spectrum Health provider and we are available to everyone in the state of Michigan.  We have created a patient experience that is easy to use so that we can provide care where and when a patient needs it.

Johnson: The patients we serve often have frequent inpatient stays, or discharges to skilled nursing or post-acute care facilities. It’s often inappropriate and ineffective care; patients leave in worse condition than when they came in. If we can manage or control these patients more effectively prior to an incident, working with their existing PCP and specialists, we may prevent a hospital visit and stabilize longitudinal health.

What do you think will be the most disruptive front door to care in the next 3-5 years?

Brennan: It’s the digital health ecosystem. Similar to Google’s digital ecosystem, it is a suite of products, not just one tool.  We will get to a point where the expectation of patients becomes that health systems will meet their needs digitally like other industries, such as banking and commerce.

Johnson: For us, it’s literally the front door. Our mission is to bring healthcare to people when they need it, where they need it. It’s simple but profound. It also allows us to bring family in. A lot of the barriers to care are around families and education and getting people on the same team. We have clinicians who can build great care plans, but also think through the barriers to care and how to ensure the patient can follow that care plan. “How can we implement this? What are the barriers? What is the family alignment that we need?” Being able to do it in the evening, on the weekend, allows us to have better conversations.

A version of this blog first appeared on the Convergence 2018 blog on September 27, 2018. 

Webinar – Capturing Patient Experience: Challenges and Future Needs

This webinar complements the release of our Insight Report, Capturing Patient Experience: Challenges and Future Needs. The webinar includes a short presentation and a longer Q&A with report author Brian Eastwood to answer audience questions about the report and broader market for capturing and improving based on patient experience data.

 

To learn more about the report or to purchase, please click here. To receive the slides, please fill out the short form on or below the video.



Podcast: The Convergence of Providers and Payers

A critical path forward, fraught with challenges

 

Chilmark’s founder and president John Moore recently took some time to speak with the producer of the Relentless Health Value podcast, Stacey Richter, to discuss current strategies of one of the biggest trends in healthcare right now, provider-payer convergence.

The discussion begins by outlining how convergence is unique compared to the many other changes and initiatives sweeping through American healthcare. Most organizations enter into these partnerships as an answer to high administrative costs, the wave of recent consolidations, and unsuccessful provider-sponsored health plans. Most importantly, a successful convergence partnership requires a deep understanding and commitment to the local market served and trust between the organizations. John also outlines some of the challenges to creating successful partnerships and suggestions to overcome or avoid them entirely. For widespread convergence success, health care organizations (payers and providers) will need to systematize both the business processes and IT infrastructure to support data sharing and actionability.

Listen here and be sure to scroll to the end of this post to see some of the content discussed:

00:00 Convergence and the delivery of health care.
02:20 “How do we deliver greater value?”
03:00 Why establishing health plans within a provider organization is often not the best idea.
04:30 How you can get around needing prior authorization and subsequently cut costs.
05:50 The motivation for a payer and provider to form a partnership.
08:00 Why consolidation doesn’t necessarily drive down costs.
08:50 Payer-provider population health management.
09:20 Understanding where the patient might be going outside of the network to get their health care.
10:00 What does it take to be good at collaboration?
10:30 “What is the opportunity here?”
10:40 “Is there a level of trust between the payer and provider?”
18:00 Advice for payers looking to partner with providers.
18:50 Look for someone wanting to deliver high-value care.
19:30 “Trust, then verify.”
23:00 New and interesting innovations coming out of current convergences.
24:00 Things still being worked out in the market today.
25:25 The innovator’s dilemma.
26:30 “How do you scale quickly?”
27:20 “Is that scalable?”
30:20 The path forward for most markets in the United States.

Throughout the program, John and Stacey touch on several Chilmark publications, available here:

Tackling Prior Auth: New Solutions to Address Provider-Payer Friction

John emphasizes how prior authorization requirements are driving up admistrative costs for both providers and payers. Even outside of a full convergence partnership, both parties can begin to work together to reduce these costs and share the benefits.

2017 Healthcare Analytics  Market Trends Report

As a population health management becomes more essential to healthcare, robust solutions are incresingly important for sharing and analyzing data from several sources, including payers, for sustainable value-based reimbursements.

Free February (and March)! Assessing the Market for Condition Management Solutions

Stacey mentions how difficult, yet important successful behavioral change can be for improving overall health. This report covers both factors driving adoption plus profiles for leading solutions for a variety of conditions and users.

Bold Move: CVS’ Acqusition of Aetna – 5 Takeaways for Delivery Chain and Health IT

John talks a little about his predictions for the future of the CVS-Aetna healthcare offerings in the podcast, including how MinuteClinics might become the first point of care. Read more in our blog about MinuteClinics, the implications for Epic Systems’ EHR, and challenges both companies face as they ambitiously attempt to transform how Americans seek healthcare.

Key Takeaway

  • PHM products are maturing in spite of uncertainty about payment system.

The Chilmark Research 2018 Population Health Management Market Trends Report, long in development, will be released immediately before HIMSS in March. This report profiles 25 vendors and describes the technology landscape for enabling a population health management (PHM) strategy.

Why a PHM Market Trends Report Now?
We hesitated to release a report on this emerging market for several years. Until recently, most available solutions were not able to fully address the range of provider requirements for PHM. The earliest solutions focused on the needs of Healthcare Organizations (HCOs) caring for Medicare Shared Savings Program (MSSP) patient panels. Over time, vendors added functionality to support bundles and private payer requirements requiring a good understanding of quality, costs, and utilization.

Another reason we held off with this report had to do with provider readiness. Healthcare delivery organizations needed time to incorporate these capabilities into their processes and workflows. The earliest HCO adopters of PHM relied on a variety of manual processes to conduct their PHM programs. Most HCOs lacked extensive experience with one or more of the constituent functional domains of PHM to fully utilize and benefit from the technology.

By early 2018 vendors had amassed significant experience building, managing, and supporting PHM enabling technology for providers and payers. Virtually all HCOs realize that PHM will be an increasingly important part of their operations and influence a significant percentage of their future revenue streams.

Virtually all HCOs realize that PHM will be an increasingly important part of their operations and influence a significant percentage of their future revenue streams.

Uncertainty About Value-Based Healthcare Makes Providers Pause
PHM’s close association with value-based care and payments cements its reputation as both a key strategy and technology enabler for transforming the U.S. healthcare system to achieve the goals of the Triple Aim. The PHM market’s growth closely mirrors the growth in value-based reimbursement (VBR). The pace of transformation to the payment system has not been smooth, and the Centers for Medicare and Medicaid Services (CMS) has sent mixed signals about its future in 2017. The business mandate for providers to embrace PHM slowed in the last 12-18 months. Provider concerns about revenue or market share losses have dampened enthusiasm for changing the fee-for-service (FFS) status quo. But the overall trend is moving in one direction: Away from FFS.

While uncertainty about the fate of value-based payments restrained provider’s embrace of PHM, the number of accountable care organizations (ACO), clinically integrated networks (CIN), and other risk-bearing programs continues to grow. Providers of all sizes have come to terms with the inevitable move to value-based contracting. ACOs will serve 10.5 million Medicare patients this year, a 17% increase over 2017. Delivering care to this expanding panel of patients requires providers, and in particular primary care providers, to organize themselves to make their PHM efforts successful. A variety of community based organizations, such as regional or state-level health information exchange organizations and to some extent payers, are also beginning to see the need to build and run PHM programs for, or in concert with, their provider partners.

Evolving Perception of PHM and the Four Technology Domains
PHM means different things to different people in 2018. Vendors built on products for pay-for-performance (P4P) programs to support CMS’ original set of ACO programs. Vendors, as a result of both organic development and acquisitions, now offer more PHM related functionality then they did a few years ago. While it is too early to say that PHM requires an established and fixed set of capabilities, the general outlines of the technology to enable a PHM strategy are broadly understood to fall into four technology domains:

  • Analytics
  • Care management
  • Patient engagement
  • Data aggregation

Most of the vendors in this report have special expertise with one or a few of these domains.

As recently as a few years ago, analytics products provided the key enabling function for most PHM programs. While this functionality has an indispensable role in PHM programs, its core functionality – cost and utilization analytics and clinical quality monitoring – is arguably the most mature aspect of existing PHM solutions. Attention has shifted somewhat to care management. The value proposition for care management stems from a perception that these workflows are the “tip of the spear” for PHM generally. Care management products are often the central tool for organizing and running PHM programs on a day-to-day basis. Payer-oriented solutions with case, utilization, and/or disease management legacy have transferable skills for clinically oriented PHM. These vendors are beginning to make inroads into provider markets. Care management capabilities are less mature than analytics but are undergoing the most rapid pace of change by vendors.

The least mature aspect of PHM from a functional standpoint is patient engagement. In most of the solutions described in this report, the care management product supports some level of interaction between patients and a care team, mostly relying on a patient portal or app. Telephonic interaction with patients still seems to be the dominant method for most providers.

Data aggregation and data source management are core competencies for PHM. They form the foundation for all of the other domains of PHM. Managing diverse data sources is complex in all PHM sub-markets and for every organization developing PHM programs. Transactions, messages, documents, and files flow in from different organizations. These sources need to be reconciled, deduped, monitored for quality, and have all of their various records matched to patients, providers, organizations, health plans, and contracts. Organizations express this data using a multitude of formats and vocabularies. Vendors must constantly monitor these transfers and streams for quality, timeliness, and completeness. Every vendor in this report has skills in this regard but they differ in the scale at which they can operate. The number of organizations and sources from which they can ingest and process data is shaping up to be an important differentiator for providers. This set of capabilities is marked by fairly mature technologies and techniques but they are being deployed against a rapidly expanding universe of health-related information.

EHR Vendors Do Not Own the PHM Market
No vendor today has anything like a “PHM Platform.” The largest EHR vendors aspire to develop such an offering and have the resources to pull it off. Hospitals and health system turn to these vendors for all of their PHM needs, but it is not unusual for them to assemble their own solution from a variety of vendors supplemented with internally developed capabilities.

But these offerings come with price tags with little appeal outside of the large HCOs. Independent physician practices, most with limited budgets and no significant IT development staffs, are more interested in turnkey capabilities from a single vendor. Often this means their EHR vendor, but just as often it means an independent vendor with a full range of PHM capabilities. While EHR vendors are fielding increasingly full-featured solutions, they have not cornered the market.

 

Bottom Line
Not all providers and payers have fully embraced value-based care and payments but the need for, and interest in, enabling solutions for PHM continues to grow. Armed with this report, providers can distinguish between the capabilities and services needed to help them meet their complex information and workflow needs for multi-disciplinary, multi-organizational teams striving to optimize the health of populations. This report will help providers sort through the different vendors and solutions in this confusing market.

Plainly Speaking: A hitchhiker’s guide to the [Healthcare IT] galaxy

I am always struck by how industries evolve language for the benefit of, and use by, its members. But membership has its privileges and its drawbacks. While simplifying ways for insiders to communicate, it excludes, or at least distances itself from, those not part of its club.

doctor shrugging, confused

Such is the state of healthcare IT, breeding an entire cottage industry of acronyms worthy of their own syllabus. Health IT is one link in the healthcare supply chain of interoperable links, and its value lies in its ability to push and receive information to and from its fellow linked parties. Perhaps if challenges and achievements in health IT were discussed in plain English, it would be easier for physicians, employers and the consumer public to digest. Our representatives in DC could also better understand how legislation helps or hinders patient care; the repeal of Net Neutrality is a timely example of the health industry failing to persuasively advocate.

Perhaps if challenges and achievements in health IT were discussed in plain English, it would be easier for physicians, employers, [our DC representatives] and the consumer public to digest.

Being somewhat versed in this code, when my physician couldn’t locate my patient record, I asked him when he subscribed to his current vendor. As the lightbulb went off in his head, he quickly navigated to a “separate patient records portal prior to EMR” subscription and found me, explaining the 30-minute delay. Further conversation revealed my practitioner was unfamiliar with much of the acronyms health IT relies on (e.g., HIE for Health Information Exchange,  HISP for Health Information Service Provider), and reported he is frustrated that his EMR vendor can not integrate his practice’s earlier patient records, nor does it provide follow-on training to him and his predominantly new staff. He added that his vendor offers no means of direct communication nor does his Accountable Care Organization have a channel or procedure for him to report deficiencies. Consequently, his pain points remain, as does a lack of guidance to his to his staff on its usage.  I can’t verify the accuracy of his statements, but the fact that he believed them to be true indicates little chance of resolving his needs, his office turnover declining, or preventing more of his patients from needlessly waiting while donned in paper gowns.

Like much of the population, I am cramming in my family members’ visits before year-end to use up my HSA dollars. As a new member of the Chilmark team, I have a few questions, in addition to my usual, of the doctors I visit. So far, the same experience noted above was reported by two other physicians. A couple more on my schedule before the year is out and I may wind up with a straight flush!

The EMR vendor’s relationship is with the larger ACO entity, but patient care is in the individual practices by the professionals administering care, and the few I spoke with reportedly felt their workflow issues remained unaddressed. All were surprised and genuinely appreciative that I sought their opinions and experiences in accessing the data they require. We should be mindful that by creating our vernacular for health IT professionals, we do not omit other stakeholders in the conversation whose participation is required for improved and engaged patient care.

Author’s Caveat: This is just my casual survey from a suburb outside NYC but I am eager for others to conduct and comment on their own.

[bestwebsoft_contact_form]