Health vs. Care and Big Data
The transactional provision of medical care in the United States is rapidly disappearing. This is the result of many converging factors. Other nations spend less per capita in healthcare, yet their citizens are much healthier. The excesses of abundance are evident throughout the population in the condition of their health. The cost of healthcare continues to increase and is resistant thus far to cost-savings efforts.
Healthcare cost is expected to exceed 18% of the GDP in 2018, and the baby-boomer generation is moving into the life stages associated with increased use of medical care. It’s not unreasonable to think that the costs could exceed 25% if solutions aren’t identified and implemented in the next few years.
The use of technology in patient care has not fully lived up to expectations through realization of a seamless care continuum. Reimbursement operations have become increasingly complex as third-party payors seek to maintain profit margins. Pay particular attention to the continued push for a single-payor system. Provision of quality health care is a challenge that will require development and use of new approaches that focus on health first and care second.
For decades, advances in care have been directed at improving detection and treatment of acute conditions. Medications have been created and regimens developed to better manage conditions that adversely impact quality of life. Diagnostic equipment has improved exponentially, and so has the cost. Facilities and resources dedicated to providing these higher levels of care increased, and it was at a rate higher than population growth.
As it’s said, “What’s old is new again.” Prior to the digital age, care was provided primarily through family physicians and hospitalizations were less frequent. This isn’t entirely attributable to better physician care. It must also account for the state of hospitals at that time and their purpose in provision of care. People recuperated at home then for conditions that warrant immediate hospitalization today. Death was a more reasonably accepted outcome for terminal diseases and people died at home without resuscitative intervention in a hospital.
At that time, the larger amount of resources were located across the wide base of a care triangle. Movement up the triangle toward the narrower top was toward a lesser amount of more advanced hospital care. Over time, hospitals and the number of physician specialists increased. Diagnostic modalities multiplied. Over time, the triangle inverted.
The top was wider and occupied by advanced care. This resulted in fewer resources providing primary care while a larger number of specialists were providing advanced care. This inversion fed itself, and the diminished primary care was unable to improve health, which resulted in higher acuity illnesses, which required more advanced care. It was more lucrative to be a specialist and the increasing number of ill made it necessary.
The solution being pursued in many quarters it to again invert this care triangle. It is believed that increased use of primary care will result in a decreased need and use of more advanced and expensive care. Add to this a focus on management of chronic diseases and associated comorbidities to reduce preventable ED visits and hospitalizations. The shift in focus is now moving from care to health. Elevate this to a level called population health management and you’ve begun to glimpse the shape of things to come.
Obesity is rampant. Diabetes is more prevalent. Coronary artery disease is common. Smoking is still popular. COPD is increasing. Behavioral health needs have increased. Substance abuse has exploded. Every one of these conditions contributes significantly to use of more expensive care. If you manage these conditions using primary levels of care that mitigate the need for advanced levels of care, you can accomplish the goals of improving health and reducing the expense of health care.
Since data drives decision-making and allocation of resources, it’s inconceivable that Big Data (BD) doesn’t have a seat at the VIP table. Financial incentives have driven or guided the focus of care, and this will continue to be the case. The key ingredient in the secret sauce is the ability to know what to incentivize to get the biggest return on investment. Information will be an absolute requirement whether the user is a regulatory agency, managed care organization, provider of health care, patient, or other participant in the health care system.
This is not about more attempts to make electronic heath systems share data with each other in support of continuity of care. That will continue along the same trajectory as before. This is about collecting data from all platforms in any format they can provide, normalizing it, generating KPIs, and performing predictive analyses of the data. Only BD can make this possible, and it will shape efforts at all levels. The benefits won’t be limited to performance data and extrapolations.
BD has the ability to make connections between disparate data elements and identify opportunities for new modalities of care delivery. Is there a correlation between HgA1c levels and medication efficacy in mental health patients? Set that as a KPI and BD will answer the question. It’s possible through machine learning that BD will discover the correlation and inform you that this relationship exists before you ask the question. This isn’t the technology of electronic medical records, interfaces, information exchanges, registries, and organic analytical tools. It’s all of the above and more.
Third-party payors will offer value-based contracting that requires improvements in quality and reduction in costs. They will determine this based on claims data they have. It will require a more comprehensive information base to strategically negotiate based on actual performance that likely isn’t accurately reflected in claims.
Since most of these contracts will be made with groups of providers rather than one-on-one, it’s imperative that the performance of the group can be aggregated, analyzed, and generate predictions about future performance. This will empower groups to negotiate contracts that play to their strengths. This is only possible through the use of BD.
Fortunately, options have emerged that challenge the standard Service as a Subscription model to gain this type of capability. A wide variety of provisioning models exist to house BD systems. Organizations can purchase economical, scalable solutions that meet their needs and hire development and analytical support externally to meet their evolving needs.
A useful analogy is that you fill your car with fuel as you drive, but you only pay the mechanic when it’s time to change the oil. The hosting and system support is the fuel costs and development and analytics are when the oil needs to be changed. Organizations of all sizes and structures should begin determining how to best meet this challenge. White papers, articles, and workshops are available to educate executive and technical staff in these options. This knowledge will facilitate engagement of resources to begin planning and implementation.
Health care is again becoming more focused on health than care. No longer will fee-for-service transactional care be profitable. A concerted effort is underway to invest more heavily in preventative care that reduces the need for more expensive advanced care. Organizations that fail are less likely to be bailed out by governmental agencies simply because they are established providers. Instead, a “to the victor go the spoils” environment may emerge where the successful no longer subsidize the failures.
Where do you want to position your organization? Consider the information presented here and research the benefits BD has to offer. It’s unlikely that organizations will be successful without use of BD in the not too distant future. Participate in workshops and seminars to identify what may benefit the organization. Begin developing a strategy regarding use of BD. Future success will be more dependent on transforming data to information than ever before.
Philip Edie, MBA, FACHE
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