A Business Case for Community-Based Care

BTBCPub Patrons:

I want to share with you a new publication that my professional colleague, Lori Peterson, played a significant role in drafting along with a member of her team at Collaborative Consulting, Sarah Milgrom. Based in good part on information generated as a result of a symposium hosted a year ago by the National Coalition on Care Coordination (N3C) this is an excellent resource underpinning the core value propositions of community-based care – and a great place to start understanding how to put integrated care delivery theory into practice.

The following is republished with permission:

New N3C Issue Brief:
Building the Business Case

The National Coalition on Care Coordination (N3C) is pleased to share our new brief, "Building the Business Case: Community Organizations Responding to the Changing Healthcare Environment for Aging Populations."

At the March 2014 American Society on Aging’s Aging in America conference, N3C hosted a half-day symposium titled Building the Business Case: Responding to the Changing Environment for the Aging Network.” With the support of The SCAN Foundation, N3C has partnered with Collaborative Consulting to create an issue brief that highlights and builds on the symposium presentations and discussions, in order to share the lessons learned with a broader audience.

The brief explores tactics for community-based aging service organizations (CBOs) to be successful in the midst of changes in the healthcare and social service sectors and increased demand for comprehensive services from the growing aging population. As more and more CBOs begin to navigate the healthcare landscape, it is important for them to learn from the experience of those who have already begun the complex process of asking critical questions of themselves and their organizational structure, crafting a strategy to lead their organizations forward, and developing working relationships and mutually-beneficial agreements with payers and health systems.

We hope that you will share this brief widely with your networks. Please
reach out to us with any follow-up questions or comments that you may have. Many thanks to Collaborative Consulting and The SCAN Foundation for their partnership on this project!

~ Sparky

Better Care, Lower Cost Act

MHLast week, Sen. Ron Wyden, D-Or, together with co-sponsors Sen. Johnny Isakson, R-Ga., and Reps. Peter Welch, D-Vt., and Erik Paulsen, R-Minn introduced the bipartisan Better Care, Lower Cost bill (S. 1932/H.R. 3890).

Wyden is broadly thought to have the inside track to succeed Senator Baucus – who has been nominated as the US’s next Ambassador to China – as the successor chair of the Senate Finance Committee. But despite the bill’s referral to that committee and its bipartisan support it is unlikely to reach the Senate floor anytime soon. Thus, Congress.

Consider that according to CMS 68% of Medicare enrollees suffer from two or more chronic conditions and account for 93% of Medicare spending ($487 billion). And 98% of hospital readmissions involve beneficiaries with multiple chronic conditions. Consider that today the Medicare system creates barriers preventing healthcare providers from building on successful integrated care delivery models.

The core concept of this bill – a Better Care Program – isn’t new. BCPs have been developed in various states as teams of doctors, nurses and social workers working together under a capitated payment arrangement. In seeking to monetize the success of those programs, the Better Care, Lower Cost bill has elements of the accountable care framework promoted under the Affordable Care Act, but there are important differences:

                      1. The underlying incentive for care coordination of an ACO is the belief that such coordination will lower costs (i.e., utilization) and result in shared savings. Under a BCP, care coordination is germane to the program (though the troublesome utilization disincentive seems to me to remain).
    1. BCPs are not impacted by the ACO attribution rule, which prevents providers from actively targeting and enrolling the sickest patients.
    2. BCPs can use pricing incentives to encourage participation in high-value care and patient activation, whereas patients covered under an ACO are not limited by where they can seek care nor particularly incentivized to engage in care management.
    3. Every beneficiary of a BCP receives an individual care plan, whereas ACOs are not required to create a plan for every beneficiary.
    4. BCPs are specifically designed to target the chronically ill with the intent of effectively managing those conditions as efficiently as possible, whereas the ACO attribution rule prohibits differentiation of patient condition or need.
    5. In theory, BCPs lack the volume-driven incentives of a FFS payment system that characterizes ACOs.

    Coordinating care across healthcare providers is intuitively beneficial to a patient – in much the same way that coordinating parental responsibilities is to a child. But where this bill falls short from my reading is its tight focus on the clinical and pharmaceutical aspects of chronic disease/care management. Long-term care, though not defined, is specifically excluded from a BCP’s requirements, though some provision is made for coordination of Medicaid long-term care benefits.

    If we are serious about wanting to utilize care coordination as the silver bullet to lower Medicare costs associated with treating beneficiaries with chronic diseases, then we will have to recognize taking a holistic approach that extends beyond doctors, nurses and drugs is necessary. It does little good to provide affordable therapy when the patient has no means of transportation. It does little good to prescribe a beneficial diet when they have no stove to cook. It does little good to prescribe medications when the patient cannot remember when and if they took the prescribed dosages.

    A successful caregiving team under a capitated payment arrangement must also include the housing and community-based services and supports necessary for individuals with chronic disease to effectively manage their own care. The thinking behind the Better Care, Lower Cost Act is headed in the right direction, but it just seems to me whomever was responsible for drafting it doesn’t really understand chronic care delivery very well.


Acute & Post-Acute/Long Term Care: How to Have That Difficult Conversation

We’ve all experienced times in our lives when we have to face a difficult conversation and the angst with which we anticipate its completion.  An example might be the nervousness and anxiety of approaching someone to whom we are romantically attracted.  Another example would be the dread and sorrow of approaching someone with news we know will devastate them.  More relevant to my purpose here are the myriad types of challenging but routine conversations that fall well within those two extremes.

In particular, I am referring to the conversations that are now beginning to take on a true sense of importance and urgency between leadership teams at acute care organizations and post-acute/long-term care (PA/LTC) organizations.  Whether driven by regulatory influence (e.g., the Hospital Readmission Reductions Program), new payment models (e.g., bundling pilots), cost containment initiatives or wanting to truly develop a full continuum of care, hospital administrators are getting earnestly engaged in wanting to understand how PA/LTC providers can help them reduce average length of stay and avoidable readmissions.

For healthcare organizations used to operating in silos, discussing subjects like strategic objectives, market positioning and perceived organizational strengths and weaknesses with other healthcare providers – let alone non like-kind providers – can be a most uncomfortable experience.  And that discomfort can cause such discussions to be entirely unproductive.  Time-wasting in today’s healthcare environment will not only put an organization at a competitive disadvantage – it is a short and narrow path to economic collapse.  So the obvious challenge is how to make sure such conversations – or meetings – are both meaningful and productive. 

From what I have observed and experienced over the past couple of years as a party to a number of these leadership conversations, there are some basic, yet very important, guidelines you can follow to help ensure the time you spend is productive and of value.  I have shared these below and hope that you find them useful.

Create a Statement of Purpose
How many times have you been to a meeting where a colleague says to you under her breath, “why are we here?” A Statement of Purpose should provide a clear articulation of why you are meeting and what must absolutely be accomplished for it to be a valuable use of everyone’s time. 
For example, a Statement of Purpose might read,

We will meet on <date> for the express purpose of creating a shared understanding of the joint-venture opportunity being considered, the attendant opportunities and risks, and whether both parties have sufficient interest in pursuing the joint-venture further.  Evidence of that interest will be satisfied if the parties enter into a Letter of Intent within 30 days following the meeting.

Drill Down on Your Value Proposition
Before meeting, have a very good understanding of why a potential venture or opportunity would be of value to your organization.  Define that value nominally (i.e., put it into real numbers).  For example, know that if successful, the project will add a net cash benefit of $X annually to your organization.  It is typically difficult to quantify economic success given the level of ambiguity at the early stages of discussion, but most executives I have worked with are usually surprised at the analytical specificity achievable when they are forced to work through assumptions and parameters.  And it is the very development of those assumptions and parameters that should serve as the meeting content (see next guideline).

Avoid Meeting Until There is Something to Discuss
I had a physician colleague tell me once that thousands of great ideas are presented and discussed at lunch tables across the country every day, yet very few ever make it back to the office – let alone to the type of initiative that merits having two organizations meet to discuss.  As Ashleigh Brilliant once wrote, “Good ideas are common – what’s uncommon are people who’ll work hard enough to bring them about.”

Generating interest and enthusiasm for a good idea (e.g., a joint venture) is usually a pretty enjoyable experience, so there is the natural inclination to want to meet and share that idea.  In my personal experience – and a lesson I had to learn the hard way – this is where most often ideas go to die.  They literally get talked into submission from exuberance over the imagined benefits before they can gain any traction and the support necessary to make it past lunch.

This is why taking the time and effort to develop the business case for a proposed venture before bringing the two parties together is so crucially important.  The level of detail should obviously be in sync with the desire to maintain a strong position of negotiation, but both parties must be able to understand the fundamental framework and objective reasoning that merit the time being committed by individuals attending that meeting.

Set Discussion Boundaries
Both parties should know in advance what they are willing and prepared to discuss.  As mentioned above, there ought to be a cognizant recognition that while bargaining in good faith should be a given, information is power in negotiation.  And while meeting to determine whether a potential venture merits further investment may not represent significant exposure, all too often information is exchanged without due consideration.  Of course, having a nondisclosure agreement in place is wise, and the terms and conditions will provide valuable guidance in establishing your conversational boundaries.

Have the Right People There – And Have Them Focused
With the advances made in information technology over the past decade, the ability to communicate with someone has never been easier – yet being heard has never been more challenging.  Competing for attention is one of the greatest singular obstacles to advancing organizational initiatives today.  It often requires a fair amount of dogged commitment, humility and political savvy to coordinate schedules in a way that gets the right people at the meeting in a frame of mind to concentrate on the meeting content.  But it is an effort that cannot be minimized without jeopardizing success.

Consider Using a Facilitator
Having a productive meeting often depends on the ability to stay focused on the deal points and ensuring you have the right levels of individual participation.  Personality types often dictate that level of participation, and without an objective means of balancing certain types, a few people can dominate the discussion – even if they aren’t the ones empowered to make decisions. 

Having a clearly defined agenda and a third-party facilitator that is familiar with your industry and business can add significant value.  That individual should have experience in effectively managing discussions and debate, ensuring that key concepts are introduced at just the right moments and have the ability artfully keep participants focused on the primary elements that comprise the Statement of Purpose.

Environmental trends and drivers are pushing acute and PA/LTC leadership teams to accelerate their interest in partnering on market initiatives that require collaborative efforts.  From the very beginning, the success of such initiatives depends on the ability to engage in meaningful and productive conversation.  By having the discipline and foresight to follow some basic guidelines those leadership teams can help avoid wasting valuable time.



Don’t Let Data Get in the Way of Good Judgment

There was an interesting article in the April 2012 issue of Harvard Business Review (Good Data Won’t Guarantee Good Decisions, by Shvetank Shah, Andrew Horne, and Jaime Capellá) that I think has relevancy to post-acute/long-term care providers.  Specifically, insights there can be useful in better understanding the significant clinical and operational challenges associated with developing the type of IT infrastructure that will help those organizations demonstrate real value as participants in integrated care delivery models.

About the Article
The authors are part of the leadership team at the
Corporate Executive Board
and they share some of what was learned through development of a proprietary tool used to assess the ability of employees to, “find and analyze relevant information.”  They call this the, Insight IQ, and through researching 5,000 employees at 22 global companies they stratified those employees into three types:
     Unquestioning Empiricists: Trust analysis over judgment
     Visceral Decision Makers: Go exclusively with their gut
     Informed Skeptics: Balance judgment and analysis

They argue that the Informed Skeptics are, “best equipped to make good decisions,”  but that only 38% of employees – and 50% of senior managers – fell into this group. Their research also uncovered four problem areas that represent obstacles to achieving better ROI on IT expenditures to develop data analysis:
     Analytical skills are concentrated in too few employees
     IT needs to spend more time on the “I” and less
on the“T”
     Reliable information exists, but it’s hard to locate
     Business executives don’t manage information as well
they manage talent, capital and brand.

Implications for PA/LTC Providers
As I have written in this space previously (and in other publications), PA/LTC providers face a challenging Catch-22 with respect to Information Technology: how to make prudent investments that position them to be competitive in a world of integrated care delivery without subverting scarce resources during a period of tremendous financial pressure.  In making such investments it is critically important to fully understand and anticipate how future IT functionality will enhance clinical and operational capabilities.

To really create demonstrable value as part of an integrated care delivery network it will not be sufficient to collect, assess, analyze and report data collected through an EHR/EMR system.  Those providers seeking to gain a distinct competitive advantage through IT capabilities will also need to demonstrate how their IT infrastructure supports tangible achievements, e.g., greater patient activation, operational efficiencies and improved productivity, higher stakeholder and constituency satisfaction scores and lower rates of hospital readmissions.

As I wrote in my recently published white paper: Strategic Planning and Positioning for Healthcare Reform,
     Data becomes Information when it is organized
     Information becomes Knowledge when it is analyzed, and
     Knowledge becomes Wisdom when it is synthesized.

The stakes are very high for PA/LTC providers entering the new world of integrated care delivery.  IT investment is a foregone certainty of participation – and with that comes the tremendous risk of not achieving the necessary ROI.  As the article points out, “investments in analytics can be useless, even harmful, unless employees can incorporate [those analytics] into complex decision making.”

And there are few industries where the complex decision making of employees carries as much importance (and risk) as in healthcare.  When developing your organization’s IT Strategy, therefore, it is very important to do so in a way that sufficiently recognizes and incorporates operational and clinical understanding.

Policy Implications
There is a lesson here, too, for public policy initiatives seeking to drive wider adoption of Evidence-Based Healthcare (EBH) and Evidence-Based Medicine (EBM). Direct caregivers – and in particular physicians – are being pressured to make greater use of EBH/EBM.  We see this in the regulatory platform of the Shared Savings Program (i.e., Medicare ACOs).  We see it in how the Insurance Exchanges are being built.  And we see it in how Minimum Essential Benefits have been defined.

I believe most physicians rightly view themselves as Informed Skeptics: balancing available data with their practice experience.  I think where very often a policy disconnect occurs is when physicians try to paint policymakers with the broad brush of being Unquestioning Empiricists: seeking to supplant physician judgment with mandated decision trees.  In response (retaliation) then, policymakers will often argue that physicians’ Visceral Decision-Making is used as a cover for the economic benefits of fee-for-service based medicine.

Of course, reality as usual, lies somewhere in the middle – beyond the interests of political campaigning.  I have always argued against mandated third-party protocols (i.e., those not created and implemented by healthcare providers) because I believe the Visceral Decision Maker brings more to the table than the authors’ research necessarily implies.  I am mindful of Malcolm Gladwell’s book, Blink, in which he explains the importance of rapid cognition and intuition – and how these capabilities are based on a lifetime of experience that exists in our subconscious.

But the key takeaway here, from a policy perspective, is the importance of going beyond the “data,” which constitutes the evidence in EBH/EBM, and understanding how data will (can) be used in provider decision-making.  The same caution that applies to organizations of being at risk of data getting in the way of good decision making thus applies equally to the development of effective public policy.

What do you think?

  ~ Sparky