Healthcare Reform

Fostering Progress on the “Four Ps” of Healthcare Transformation

Fostering Progress on the “Four Ps” of Healthcare Transformation

Adam Boehler recently spoke with policy advocates and HIMSS about the “Four Ps” of value-based transformation in healthcare. It was a clear, simple way to organize a complex topic, so we’d like to help amplify his message for the broader health IT community.

First, here’s what you need to know about Boehler. He serves as deputy administrator at the U.S. Centers for Medicare & Medicaid Services (CMS), where he directs the Center for Medicare and Medicaid Innovation, also known as the CMS Innovation Center. Before joining the federal government, Boehler was a patient-focused leader in private-sector healthcare. He was appointed as senior adviser on value-based transformation by U.S. Health and Human Services (HHS) Secretary Alex Azar.

Now, let’s look at the “Four Ps” guiding Boehler’s public policy work and what they might mean for health IT leaders.

Based on our own notes, these are Boehler’s “Four Ps”:

  1. Patients empowered to drive value as consumers
  2. Providers working as accountable navigators of healthcare
  3. Paying for outcomes (rather than for procedures)
  4. Preventing disease before it occurs or progresses

Each of these four paths of transformation has implications for anyone involved with healthcare data, analytics or information technology. Let’s take them one at a time.

Patients Empowered as Consumers

American healthcare is not currently a consumer-driven market, but federal policy leaders are pushing in that direction. This eventually should result in more transparency around pricing, better interoperability between providers and easier data access for patients.

Patients cannot act as consumers and they cannot drive value without easy access to information about their health,” said HHS Secretary Azar in his HIMSS19 remarks.

Patient data access requires interoperability. That’s the standardized, secure, user-friendly exchange of electronic health information. Unfortunately, the interoperability challenge is formidable and won’t be solved overnight. It’s actually one of those policy challenges that has taken decades to solve.

Many significant pieces of healthcare legislation—including HIPAA in 1996, the HITECH Act in 2009, the Affordable Care Act in 2010 and the 21st Century Cures Act in 2016—have touched on interoperability. In 2014, the Office of the National Coordinator for Health IT (ONC) created a 10-year nationwide interoperability roadmap.

One of the components for interoperability identified in the ONC roadmap remains a key issue today: “accurate individual data matching.” Participants in the U.S. healthcare system (patients, providers and payers) need reliable patient matching to make sure they can securely, quickly and accurately connect patients with their data.

An October 2018 report from The Pew Charitable Trusts underscored the need for this patient matching capability. The report, “Enhanced Patient Matching Is Critical to Achieving Full Promise of Digital Health Records,” offers detailed findings and recommendations that are worth a look.

More broadly, CMS is currently proposing a new rule that is “intended to move the health care ecosystem in the direction of interoperability.”

The push to empower patients as consumers (and to make information interoperable) goes on.

Providers Accountable for Outcomes

If current trends continue and regulatory efforts bear additional fruit, healthcare providers in the United States increasingly will be held accountable for the quality of care they deliver.

Accountability can mean different things professionally, administratively and economically, making it hard to predict where the rhetoric ultimately will meet reality. Regardless, from a health IT perspective, there are several foreseeable effects:

  • We can expect continued innovation in infrastructure to support accountable care models.
  • We can anticipate continued standardization of data to support clinical quality reporting.
  • We can imagine greater integration of multi-source data at the point of care to help providers form a more holistic health picture and treatment plan for each patient.
  • And, consistent with the interoperability discussion, we can see increasing demand for patient (and provider and payer) access to comprehensive personal health information. On a related note, we will continue to see growing demand for consistently refreshed and accessible data on provider quality, credentials and outcomes. (For payers, IDC recently issued its report on U.S. provider data management vendors.)

Accountable providers and empowered patients ideally can work together to drive value, while payers ideally can reduce costs by fundamentally changing the reimbursement model.

Payments Moving to Value-Based Models

Currently, healthcare payers are paying for procedures rather than results. For example, in his HIMSS talk, Boehler cited the fact that an ambulance service can only get reimbursed if it transports the patient to a medical facility, whether or not it’s medically necessary.

This is one small example of the biggest systemic problem in U.S. healthcare: cost. You’ve seen some variation on these statistics, we’re sure: America’s per capita health spending is twice the comparable country average and our health spending continues growing relative to our economic growth, yet our life expectancy remains lower than comparable countries. Within a few years, one out of every five U.S. dollars is expected to go to healthcare expenditures.

To help address this cost issue, Boehler’s team at the CMS Innovation Center is testing seven different types of “innovation models” for payment and service delivery.

For the health IT community, any overhaul of payment systems, methodologies and processes will mean more changes, whether minor tweaks or major migrations, to absorb and encode. It will get more complex before it gets simpler.

Over the long run, the movement toward value-based payments should serve to reduce costs as intended by incentivizing efficient treatment.

That’s all well and good, you may say, but what if we were able to move more holistically from our reactive “sick” care system toward a truly proactive “health” care system?

This brings us to Boehler’s fourth and final “P”: prevention.

Prevention Before and Beyond Clinical Intervention

Enabling more effective prevention is another good way to reduce costs while increasing quality. It involves considering each patient (and prospective patient) as a whole person.

Ramped-up prevention means bolstering an array of social services in order to counteract the social and economic drivers of diseases, health crises and addictions. It encompasses improvements in housing, food, jobs, education and community safety, for example.

These non-clinical factors influence health outcomes more than you might think. In fact, a September 2018 report from the University of Wisconsin Population Health Institute suggests that an individual’s “Social & Economic Factors” (education, employment, income, family and social support, and community safety) are responsible for 40 percent of his or her health outcomes, whereas “Health Behaviors” account for 30 percent and “Clinical Care” factors account for 20 percent.

Looking through the healthcare lens, a renewed focus on preventive social and economic strategies can create non-clinical interventions that improve health and thereby reduce healthcare costs.

From a health IT standpoint, this prevention-driven policy path translates into an increasing need to develop a systematic understanding of the social determinants of health. With the right socioeconomic data and advanced predictive analytics, health IT leaders can further support their organizations’ needs for smarter risk assessments, more effective prevention, greater patient adherence to treatment and higher quality ratings.

Boehler’s “Four Ps” of value-based healthcare transformation clearly got our wheels turning. His team’s push for more well-rounded, value-based, patient-centered, accountable care creates more innovation opportunities for all of us in the health IT ecosystem.

Sponsored content. The views and opinions expressed in this blog or by commenters are those of the author and do not necessarily reflect the official policy or position of HIMSS or its affiliates.

HIMSS Government Relations

The HIMSS policy team works closely with the U.S. Congress, federal decision makers, state legislatures and governments, and other organizations to recommend policy, and legislative and regulatory solutions to improve health through information and technology.

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