Examining the Possibilities of a 360-Degree Healthcare Continuum
26 May 2008
Healthcare in America is among the best in the world, yet has remained at the center of debate for more than a decade. Rising costs and access to care make the system work for some, but not for others, raising a growing need for healthcare reform.
Healthcare Transformation: Getting There
The U.S. healthcare system needs systemic changes to improve care and control costs. In this paper, EDS examines how government agencies can address the issues and opportunities facing consumers, providers and payers, as viewed through the lens of The 360-Degree Healthcare Continuum.
Download the full version: Healthcare Transformation: Getting There PDF, 338K
But there is no easy fix or singular approach that will untangle the mess. It's not one solution or one program, one change or one initiative. In fact, it's likely to be a great many changes at different levels and from multiple sources.
However, that doesn't mean that change is impossible. EDS suggests that one way to move towards improvement is for healthcare payers, especially within state government, to dynamically transform their role in the process.
Penny Thompson, the director of Government Health and Human Services Strategy and Portfolio for EDS, suggests a model she calls the “360-Degree Healthcare Continuum” as a guideline to change part of the larger system. Within this model, payers become information brokers, utilizing data, statistical analysis and interactive systems to optimize a patient's care program. The end result is a better outcome for the consumer, a more positive experience for the providers, and significantly lower costs for the payer over the long term.
Thompson believes the potential for innovation, impact and breakthrough return on investment is greatest when the system focuses on achieving progress through the following methods:
Improving the Distribution of Knowledge in Healthcare
Today's healthcare system is “data rich but information poor.” Payers see data on encounters and claims but lack detailed clinical or beneficiary information. Providers see information relating to their own direct patient encounters but do not have easy access to a patient's full history. Patients have limited information on their own care and services, and have a more difficult time making smart decisions as a result.
A better exchange of this knowledge base will create a transparency that empowers payers, providers and patients alike. For example, each year more than $16 billion is spent on unnecessary high-tech imaging tests. Improved information exchange and interoperability between outpatient providers and independent laboratories that reduces unnecessary tests and associated administrative costs could save the U.S. healthcare system as much as $31.8 billion a year.
Educated Consumers Positively Impact the Healthcare System
Under the current system, changes in economic conditions, living arrangements, employers and insurance offerings cause consumers to enter and leave different provider networks and plans. This often means changing doctors or other providers, and receiving health information from a variety of sources. Consumers must be empowered to make good decisions on prevention and healthy lifestyles, understand how to navigate the complex healthcare delivery system to get the care they need, and customize medical and social support systems to their personal circumstances and conditions.
Educated consumers who understand both their medical needs and their options for care can have a positive impact on the system as a whole. Their choices can reduce unnecessary or inappropriate healthcare consumption and, in some cases, improve their personal health through lifestyle change. They might also drive the market towards greater price and service sensitivity.
Improved Performance in the Healthcare Industry
Care management programs that include predictive modeling and effectively engage providers and beneficiaries can have a positive impact on costs and outcomes by helping providers identify patients with the highest risks and biggest gaps in care. Payers and providers can then collaborate to address the highest-risk, highest-cost patients, benefiting all parties. This approach allows payers to work in collaboration with patients and providers to promote safety, quality and value.
Streamlined Business Processes
Government-funded state health programs are extremely complex. Providers are often reluctant to take on the administrative complexity, specialized requirements, paperwork demands and claims auditing procedures. As a result, fewer and fewer providers are available to serve a growing need for services. On the other side of the equation, beneficiaries must navigate complex eligibility requirements and numerous program rules to access coverage. Some consumers go without care because they are unable to work through the system.
Payers must deconstruct the way they do business to reduce administrative costs and effort, and promote efficiency and effectiveness. This change will increase provider participation rates, reduce inappropriate expenditures and unnecessary costs, improve uptake in enrollment of eligible populations, and improve program integrity.
Leveraged, Modernized Infrastructure and Applications
A shared services or utility environment with systems leveraged among commercial and government payers, as well as providers, would benefit a larger community. Partnerships among commercial and government payers and within state agencies for the shared use of applications and infrastructure for common work elements (document management, case coordination, intake and referral, etc.) will reduce investment and capital expenditure as well as ongoing administrative expense.
Working through these steps, government payers can work within a total healthcare system framework to drive significant advances. Thompson envisions a maturity path as having the stages and characteristics similar to the one below:
Characteristics |
Current Stage |
Next Stage |
End Stage |
|---|---|---|---|
Knowledge |
Disorganized |
Accessible |
Embedded |
Consumers |
Affected |
Active |
In control |
Performance |
Variable |
Improved |
Optimized |
Administrative |
Complex |
Simplified |
Automated |
Systems and Applications |
Rigid, siloed |
Flexible, componentized |
Shared |
While the 360-Degree Healthcare Continuum is by no means the solution to healthcare reform in the United States, implementation of its elements could improve delivery for the short term and provide flexibility to adopt future healthcare financing and delivery decisions as they are made on the national and state levels. Most significantly, the model will position states to be at the forefront of transforming U.S. healthcare to a value-driven, integrated enterprise.