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2015 seems like a long time ago. Value-based purchasing for health care had gained traction and the Department of Health and Human Services (HHS) launched the Health Care Payment Learning & Action Network (HCP-LAN) to organize private, public, and nonprofit stakeholders to transform our health care system by embracing value-driven reimbursements via alternative payment models. In turn, the HCP-LAN quickly developed white papers, webinars, and national meetings to seize the moment and restructure health care incentives to reward effective patient management.
Two years later, at the January 2017 HCP-LAN Guiding Committee meeting, the tone had changed considerably. The contentious 2016 presidential election was in the air and a committee co-chair memorably commented, “Elections have consequences.” Health care leaders adopted a wait-and-see approach to alternative payment models, which limited enthusiasm to emerging initiatives. This uncertainty prevailed for months.
Increasingly, government leaders shifted toward risk-based alternative payment models (APM) in which the health provider assumes financial responsibility when targets are not met. This approach favored management of larger populations of patients to dilute risk associated with sicker and costly outlier patients. The LAN moved away from a focus on clinical judgement models that valued professional expertise to management strategies for large integrated organizations. Exploration of the economics of organized health systems became more central than bedside strategies of disease management. The bloom of the LAN rose faded and the APM momentum slowed.
And then 2020 arrived with the pandemic and its associated chaos. Years of increased hospital efficiencies limited capacity of institutions to react to surges in critically ill patients. A February 2020 estimate of COVID mortality/morbidity presented on a national American Hospital Association webinar seemed ghoulishly fanciful at the time but was optimistic in hindsight. Health system survival and public health infrastructure took precedence over alternative payment models.
As a member of the inaugural boards of the National Quality Forum and the HCP-LAN, I have seen the optimism of new multistakeholder ventures tempered by the reality of disease complexity and incomplete health system information. Financial accountability for outcomes without robust, accurate clinical data inputs remains a halfway intervention. Current management strategies are responding more to published rules rather than solving fundamental delivery challenges.
What should be the focus of the HCP-LAN as we emerge from the COVID chaos?
Ultimately, the strength of a health system rests on decision-making at the bedside. There is need for granular, accurate data and decision support at the point of care and there are signs that we are moving in that direction. The Office of the National Coordinator (ONC) has numerous task forces generating new models of clinical data extraction to be integrated into data flow at the point of care. New requirements for Fast Healthcare Interoperability Resources-API data standards expected at the end of 2022 could substantially enrich information systems that guide clinical decision making. Integration of social determinants of health into electronic health records has the potential to strengthen care plans that would then create strategies that reflect the daily reality of the patient and their personal health challenges at home as well as in the hospital.
The HCP-LAN could shift some of its recent focus on the C-suite back to clinical decision makers and highlight multipayer, innovative strategies for implementing effective patient care. For example, integrated information systems are needed to improve patient flow and outcomes. Thoughtful use of telemedicine to support patient care could streamline clinical strategies so long as the technology does not create new fragmentation of services. LAN could evaluate the value of health insurers doing home visit assessments independent from a patient’s clinical providers and whether a patient’s care plan fit the reality of their daily life.
Current political polarization has dampened evidence-based discussions and planning. The absence of consistent, coherent policy directions from the beltway has limited creativity for patient-centered solutions and promoted more bottom-line management of acute care needs. Venture capital and publicly traded corporations are buying health care assets with an evolving impact on clinical cultural norms. There is a growing overhang of unresolved issues related to sustainable services for patients with chronic health conditions. Furthermore, COVID restrictions have reduced interactions of thought leaders and administrators at regional and national gatherings. All of these elements have produced this current era of policy stasis and growing uncertainty.
The last two years have proven stressful to administrators, budgets, policymakers, and patients. The HCP-LAN community has suffered its own form of burnout. It is time to rekindle optimism about transformation to a better health system. We need to highlight multipayer approaches to supporting emerging new models of patient-centered care and sustainable work environments. While the new envisioning of CMMI is interesting, the policy community must go beyond stating well-meaning statements to actual implementation of workable models to achieve the egalitarian frameworks. Humanistic, patient-centered care requires a bedside workforce that makes happen. The gap between administrative offices and the bedside needs greater attention to empower health care transformation.
The HCP-LAN can be a pivotal force in reenergizing health care by promoting payment for evidence-based opportunities for better patient-centered operations in organizations large and small, as well as exploring the importance of clinical culture on patient experience. It is the right time to catalyze a vision for renewal.
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