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Receiving Outcome Incentive Payments Requires more than “Outcomes” from Providers

Paying healthcare providers to meet defined quality goals has experienced an uptick in acceptance and appeal lately.  Given the fact that the quality of care in the United States has been unresponsive to decades worth of public reporting and benchmarking efforts, one can’t help but to wonder if a financial incentive to providers and physicians will be of much use. 

Within the past few months, heavy hitters such as UnitedHealth Group and WellPoint announced that they will change the way they pay providers and hospitals.  The goal of this effort is to overcome fee-for-service short-comings by making patient outcomes a part of payment structures. 

This is a concept that has long been hailed as a solution to overcome the rapidly inflating healthcare costs and unresponsive outcomes.  The 2001 Institute of Medicine (IOM) report titled, Crossing the Quality Chasm, discussed how U.S. healthcare quality failed to establish benchmarks to measure care based on the best available practice.  It stated that the problem with outcomes within the healthcare industry is based in the fact that provider practice patterns differand those differences in practice patterns are responsible for staggering differences in cost of care and outcomes.  Ultimately, the report suggests that providers who want to address outcome discrepancies should start by adhering to evidence-based practice patterns.

Provider Needs
This introduces two needs for providers:  Knowledge of Best Practice Patterns (Order Sets) and Business Intelligence. Providers who adhere to evidence-based order sets are expected to have increases in treatment outcomes.  However, before any provider changes their practice patterns there must be evidence that the change works.  For example, the Grey Bruce order set project   found that physicians using order sets were 143% more likely to order a specific life saving drug for heart attack patients if they used an order set.  If the proper evidence is supplied then the first hurdle is negated.

The second hurdle to improving outcomes and adhering to order sets is accessibility to a robust evidence-based clinical decision support system to improve outcomes and lower costs per case.  Part of this system should be a repository to keep physicians abreast of the relevant publications regarding order sets and other evidence based practice insight.  The second part of the system should track and report out on physician order sets within their facility.  By having access to the appropriate scholarly publications and facility physician practice patterns, physicians may find that certain “tweeks” to an order set improve outcomes at their facility or within a certain group of patients while other “tweeks” may hinder outcomes. 

Most of the necessary data is captured by systems within an organization, but many organizations are struggling to find a way to access and use the data.  Whether the goal is to meet the financial incentives offered by providers or to lower costs of care, it is impossible to address practice patterns and outcome issues without a business intelligence solution that provides insight into the business and/or physician.  Organizations investing in such systems will not only have a leg up on competitors, but they will also be more likely to meet the incentive payment requirements – and ultimately have healthier patients and receive more money from payors. 

The future of healthcare looks much different than yesterday.  For organizations and physicians who are nimble and stay in front of the curve, survival will be fairly painless.  The rest – they will learn to evolve.

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