Healthcare Payment Reform

Drivers of Healthcare Analytics

1Medicine is ChangingTO a profession-based practice, organized around patient or disease state, where groups of peers, treating similar patients in a shared setting, execute coordinated care delivery processes using agreed upon clinical guidelines and disease management protocols.

FROM a craft-based practice, in which individual physicians, working alone, create a customized solution for each patient based on their personal knowledge and training and a core ethical commitment to the patient.2This transformational change in the medical delivery model is being driven by payment reform, and will be accompanied by: individual physician autonomy and hierarchy replaced by clinically integrated, team-based systems of caregreater provider accountability for population health costs and outcomesa significantly higher level of provider financial riskHow Healthcare is Currently Purchased3

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Alternative Value Based Payment ModelsLimited IntegrationModerate IntegrationFull Integration

Provider Financial RiskPayer Financial Risk84Payment ModelClinical Organization and DeliveryIT/AnalyticsFFSP4P

organized around medical specialty and hospitaldisease focus, one patient at a timehierarchal culture and high physician autonomylow provider accountability for cost and quality of carelimited EMR interoperabilitylimited provider financial risk

Access databases and spreadsheetsretrospective dashboardspayer provided performance reportsdisparate EMRsShared Savingslow-to-moderate clinical integration and physician-hospital alignment some proactive chronic care and complex case management, though most visits still reactive to patient complaintspayer-defined patient care protocols and risk stratificationmodest provider accountability for cost and quality of care for a defined patient populationmoderate level of provider financial risk

early stage predictive analyticspayer provided risk scores and performance reportsearly stage EMR interoperabilityPayment ModelClinical Organization and DeliveryIT/AnalyticsBundled Payments

increasing clinical integration and physician-led care coordination teamsuse of provider-defined, evidence based care management protocolspatient care cost, quality and outcomes actively monitored and reportedpatients actively engaged in their carequality control systems reduce variation and minimize error meaningful provider financial risk

mature predictive analytics capabilityprovider defined cost, quality and outcome measurement and reportingadvanced EMR interoperability or single, system-wide EHRShared Risk

Capitationproviders organized around patient and population needssystem-wide acceptance and adherence to provider defined care protocols clinically integrated, team-based systems substitute for hierarchy and result in seamless care for patientscare quality transparent and value-oriented internal data warehouse collects data from multiple sources for sophisticated health risk modelingsignificant provider financial risk

sophisticated population/process analytics capabilityfully integrated clinical and financial data systemsHIEs and EMR interoperability provide a real-time, longitudinal patient view