Health IT is a key enabler of new payment models that pay for health care value, rather than for each incidence of care.
Accountable care has been an important topic of conversation lately. But even before the federal government launched several accountable care organization programs, ACO-style payment arrangements already had been adopted by private insurers.
Health plans and large employers have tried for some time to direct patients to preferred providers as a way to control costs. This has become even more important as mounting evidence shows that high costs do not necessarily signal high quality. HMOs directed patients to particular providers by using closed networks in the mid-1990s, and some have said that ACOs are just the same old pig in a new dress.
But today health plans are attempting to engage patients through new value-based network designs. The financial bonuses that ACOs can receive if they meet quality and cost benchmarks drive improvements in care quality and lower costs. This in turn gives providers an incentive to coordinate their patients' care to reduce duplication of services, invest in infrastructure like health IT, redesign care processes and practice with a greater adherence to clinical evidence.
Value-based provider networks attempt to help consumers make informed decisions about their care, while maintaining their ability to choose a provider. This comes from some of the lessons learned from a backlash against HMOs and restricted provider choice and has been enabled by technology, which allows improvements in measuring provider performance. In a value-based network, health insurers sort providers into tiers based on cost-efficiency and quality performance measures. Providers achieving higher efficiency and quality scores are placed in a preferred tier, and patients have financial incentive to choose these providers. The use of health IT will be used to help gauge efficiency and quality.
Payers have embraced the concept of accountable and coordinated care and have made substantial investments in health IT to support these new designs.
The role of the health plan is indeed changing. As Mark Bertolini -- Aetna CEO, chair and president -- said during his keynote at the HIMSS conference, "The system doesn't work. It's broke today. The end of insurance companies, the way we've run the business in the past, is here." He added that technology is crucial to redefining this relationship.
Over a year ago, Aetna purchased health information exchange vendor Medicity. Combining Medicity with the Aetna-owned technology ActiveHealth Management clinical decision support system helps create a complete infrastructure for providers to operate as an ACO. Aetna also has acquired the mobile health startup, Healthagen, which developed the popular health app iTriage. Aetna is leveraging the mobile application in its ACO offering, where it will be a key component for consumer engagement.
In a stunning announcement, Bertolini said Aetna will be giving away Medicity's software development kit for mobile app creation to the public domain, hoping to create an app store of sorts for health information exchange. I have no doubt that the changing role of the health plan will be enabled by innovative technology solutions.
At this year's HIMSS conference, I asked Brent Dover, president of Medicity, about any initial reticence among customers and potential clients around security of data since the acquisition by Aetna. While acknowledging some initial concerns, he stated that by the second half of 2011 those fears had about evaporated.
"At first there was concern, but our clients found out that nothing happened and others realized the data [were] still safe," Dover said, adding, "The ability to securely exchange key clinical data is one of the most critical but missing elements in helping to drive more cost-effective and higher quality patient care."
Charles Saunders, head of Strategic Diversification at Aetna, made the case that there are two sides to accountable care, the provider and the patient. "We believe in supporting the consumer with what they need to be a partner in their health care; to understand their options and navigate the system in a way that's convenient and efficient; and armed with the tools that can help them make informed decisions, which means full price transparency, as well as clinical data," he said.
UnitedHealth Group's Efforts
Like Aetna, UnitedHealth Group has made some large acquisitions in the health IT arena and is using them to help drive innovations in payment models. In 2010, UnitedHealth Group's health IT division -- formerly called Ingenix and now known as OptumInsight -- purchased Axolotl, a health information exchange vendor. Axolotl is now part of OptumInsight's portfolio of health care management systems and services.
Optum has introduced its Accountable Care Solutions group and recently worked with Tucson Medical Center and local physicians to create what they are calling a "Sustainable Health Community" based on the ACO model.
It also has launched the Optum Care Suite, a set of applications that will help physicians and other health professionals access detailed health intelligence on patient, system and population health, and collaborate to make medical care decisions and improve health outcomes.
"Optum Care Suite provides a broader and more useful view of patient and community health, removes technological barriers to patient-centered care and automates the gathering of information for administrative and reporting requirements," said Andy Slavitt, group executive vice president at Optum.
UnitedHealth also has partnerships with the mobile health IT companies CareSpeak Communications, Lose It! and FitBit, as part of a mobile health strategy.
In addition, Optum has launched an open-cloud platform to allow developers to create and host health care applications. The Optum health cloud uses Cisco's networking and security; EMC-enhanced Java and virtual machines; IBM back-end data processing and business-intelligence applications; and HP servers and analytics.
Optum demonstrated the cloud service at the HIMSS conference, noting that the health cloud could enable health care organizations to reduce some of the costs and time required by creating apps and bringing them to market by utilizing a tool kit for CIOs to enable deployment of internal and external applications. The health care cloud will connect patients' applications with biometric monitors and the health information systems of doctors, hospitals and health plans.
Importance of Data
Data are king, and getting all the data needed to really move the needle on accountable care is challenging. At a Think Tank event sponsored by Dell Healthcare at the HIMSS conference, I proposed that "big data is the next big thing in health IT," and as we gather and aggregate all of the data needed to support new payment models, we will need to be able to apply analytics tools to the tidal wave of health data heading our way.
Some is this data will surface as Aetna, Humana, Kaiser Permanente and the UnitedHealth Group make claims information available to the newly formed Health Care Cost Institute. The new institute will provide claims information to qualified researchers seeking to analyze the data, and it will make public summaries that identify changes in health care prices and use of medical services. The insurers will not have access to the aggregated pool of private data and the data will not be accessible to the public.
There also is a need at a local level for data sharing for better care coordination and to aggregate data for quality reporting and population health management. The technology foundation to make this possible is being built, and the pipes and plumbing for data sharing are being developed. But we will need intelligence in those pipes and the ability to apply analytics tools and business intelligence to the datasets to achieve this vision.
With electronic health record adoption scaling upward, health information exchange efforts heating up and recognition that we can no longer continue down the unsustainable path we are on, there is opportunity to leverage technology to find a better way.
Looking at all of the energy that the government, private health plans, providers and technology vendors are putting towards transforming our health care system makes me a bit optimistic. I believe that the private market is able to be much more nimble than government and that we will see some great innovations in technology that will enable the health care system of the future. As HHS Chief Technology Officer Todd Park has said, "There has never been a better time to be an entrepreneur -- an innovator at the intersection of health care and IT."