When it comes to changing behaviors in healthcare, incentives matter. Look no further than the reimbursement incentives CMS put in place with value-based care and chronic illness. Healthcare systems that billed fees for service are now interested in solutions to help them tick the box operationally and clinically, so they maximize their reimbursements. Yet, in my previous post on the short term approach to chronic illness, I highlighted the need to move beyond the operational and clinical focus on which most chronic illness solutions concentrate. There is certainly value in using these solutions, but the point of my post was to highlight that long term success in treating chronic illness will require addressing non-clinical barriers to improved health literacy: patient language, education and culture.
We can certainly agree clinical and data fragmentation has an effect on direct patient care, but communication fragmentation is actually far more complex. Data and organizational fragmentation are amplified when it comes to communications. There are communications from the healthcare provider, healthcare payer and pharmacy. Take a look at the following issues:
- Various independent health groups may be treating a chronically ill patient – and every single one of them has their own treatment instructions and patient communications. These communications look different and may offer varying capabilities in terms of addressing language and readability barriers.
- The IT strategy for these organizations may have different cultures regarding the implementation and use of information technology. Some may be procurement driven and others more strategically driven. This seems like a small difference, but it results in a massively different approach regarding the implementation of third-party applications.
- There has been massive outsourcing of services within the healthcare industry which creates its own set of challenges.
Patient care occurs primarily in the clinical space. Patient communications occur in all elements of a healthcare journey. This post will highlight some of these groupings of communications and show how they may be owned by different management groups within the healthcare ecosystem. This is important because each business owner has their own goals and strategies regarding the creation, production and distribution of patient communications.
On to the communications
I created the following graphic for my first post on this blog to document the variety of clinical and non-clinical touch points that take place in a healthcare encounter.
I color coded each touchpoint in red, yellow or green to highlight how well they lend themselves to two-way communication. I did this because our best opportunity for creating a comprehensive AND accurate clinical and non-clinical health record requires us to provide, AND elicit, information in every single healthcare touchpoint
Who is the business owner?
We will leave the primary care and specialist interactions off this discussion. They represent in-person interactions and offer two-way communications documented in the EHR system.
But let’s look at the rest of the clinical and post clinical interactions. Most every one of them represent push communications where information is handed to the patient with little to no activity that collects critical non-clinical data from the patient. Furthermore, the actual owner of each touchpoint communication varies in terms of organization and business owner.
- Care Instructions: Handed out at the doctor’s office. Likely printed out of the EHR system. May have some varying language capability, but most likely printed in English. Application Owner: Maybe IT or operations
- Prescription: Instructions provided at the pharmacy. Printed out of the Pharmacy IT system. Dense language with all sorts of dire warnings. Most thrown away without even reading. Application Owner: Pharmacy IT or operations
- Physical Therapy: May be part of health system or some stand alone organization. Instructions printed onsite. Likely limited in terms of language. Third party organizations have no connection to healthcare system EHR. Application Owner: Varies
- Health Technology: Digital Technology that might be phone apps, wearable technology and more. Value as data gathering tool is mixed. Requires strong accurate involvement of the patient. Even more, the vendor may own the data, not the healthcare system. Application Owner: Likely third party
- Call Centers: May be outreach in the form of coaching chronically ill patients, but more likely reactive and in place to answer questions from members and patients. Many are outsourced with limited skillsets in call center personnel. Likely considered a cost item. Likely not used strategically. Application Owner: Varies, especially if outsourced
- Explanation of Benefits: Owned by the Payer or PBM and sent out monthly when the patients have some form of interaction and claims cost. Viewed as a cost. Some marketing messaging embedded within the communication, but primary use is claims. Application Owner: Varies, maybe Admin or Operations. Actual work likely outsourced
- Provider Billing: Just as it sounds. Billing statement on what the patient owes. Viewed as a cost. No strategic effort behind it. Just get the payment. Application Owner: Varies, maybe Admin or Operations. Actual work likely outsourced
The tangled webs we weave
If we were to try to use every one of these touchpoints as a tool to build healthcare literacy in chronically ill patient populations, there are a variety of reasons why we would need to coordinate data and IT infrastructure:
- A minimum of three organizations send out communications. Payer/PBM, provider and pharmacy. The provider may even be fragmented if the primary care physician, specialist and therapist are associated with different organizations.
- Each of these communication touchpoints are likely owned by different business owners within their respective organizations. Rarely will you find one overall manager for every single communication touchpoint, even in the same organization. Currently, there is little incentive to collaborate.
- Most every communication on this list is viewed as a cost. That means the goal is to reduce the cost of creation as much as possible. Any effort to enhance them is viewed with suspicion, especially if it drives up the cost in any way.
- Many communications are outsourced, especially call center, EOB and billing. Even the health technology aspects may be procured from outside vendors with their own limitations or reluctance to connect any of their data to the larger patient EHR ecosystem.
- Any outsourced work will be limited by the capabilities of the vendor platform.
So yes, we can say there’s an effort to coordinate care. We can say everyone is finally on board to make this happen. But what are they really coordinating? Are they working primarily for the benefit of the patient? Or are they only looking for operational and clinical data, allowing them to check the box and capture the incremental improvements in reimbursement as specified by our government? Right now there are no incentives to coordinate communications.
The dog needs to wag the tail
Given the tight margins most healthcare systems operate under, you can hardly expect them to take the lead, coordinating the data hand-offs and the communication messaging across all the various organizations working with chronically Ill populations. For decades they have lived and worked with a “fee for service” model. Now the government has mandated certain operational and clinical targets to maximize reimbursements for chronic illness. These small incentives have created positive change.
There are no programs promoting changes in how we coordinate communications. To drive meaningful change in coordinating these communications, and addressing the fragmented communication preferences for chronically ill populations, we need government and large payer involvement. Incentives matter and they are best positioned to enforce change in healthcare systems and patient behavior via reimbursement incentives.
Until that happens, the best we can hope is some of these organizations figure it out on their own and their efforts will improve health literacy and outcomes for the chronically ill populations they support. In other words, we will improve on a fragmented basis instead of institutionally.
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