Of the nation’s 3.5 trillion in annual health care spending, 90 percent is for people with chronic and mental health conditions. How long can this continue? Can health care institutes afford not to engage in the 2020 wave of preventative care health care disruption? For those riding the disruption wave, the answer is simple. CMS alone is providing more than 80 billion in reimbursements for preventive care initiatives. This calculation does not count on complex chronic care conditions and other follow-ups from preventive care engagements.

Also, CMS aims at containing the growth of acute care reimbursement. It has almost the same “carrot and stick” model used for the evolution from paper to electronic. Stay on the paper train and get penalized or get on the preventative care train and receive financial incentives.

Earthquake or hurricane?

Both natural disasters are simply disasters. Earthquakes cannot be foreseen. A hurricane cannot be monitored to the exact point of where it will hit, but it can be monitored to approximately when it will hit and its impact.

The paper evolution is like an earthquake to health care with its aftershocks still being felt today. The preventive care evolution is more like an imminent hurricane. We know it is coming, but we don’t know where it is going. We need to deal with it and manage where it will take us.

Most health care institutes have deployed an EHR system, almost completing the evolution from paper to electronic medical records. This was the first wave of health care disruption. We now recognize this was much more of a disruptive process in health care than it seemed as its impact has gone beyond how patient medical data is recorded.

Power vs. paper

It began with requirements for care providers to use an electronic system in place of the traditional paper approach, creating a patient medical information exchange and improving care quality and efficiency. CMS rolled out preventive care reimbursements starting with the annual wellness visit (AWV) in 2015.

CMS continued to invest in preventive care with additional reimbursements such as chronic care management, remote patient monitoring, behavioral health integration, and transitional care management. Every year, CMS either expanded current reimbursements or deployed new preventive care services. This strategy was based on the patient-centered medical home with the objective to curb health care costs with preventive care measures, a 6:1 ROI versus acute care.

Preventive care

Today, it is all about preventive care. Providers anticipate and monitor conditions before the patient encounters a serious medical problem. This causes changes in the operational workflows for health care institutes.

In the acute care patient engagement model, it is the patient who makes an appointment or visit. For preventive care, it is care providers and health care institutes conducting the outreach. However, without the patient outreach model, health care institutes cannot realize the full financial incentives offered by CMS.

In the acute care environment, providers cannot bill for the engagements but can bill for visits and appointments. In the preventive care environment, providers can bill for services, but it is up to care providers (and their staff) to reach out, monitor patient conditions, and meet the time required for billing.

Then there is the question of scalable bandwidth. In an acute care environment, the patient’s coverage is limited to the traditional eight-hour shift. That model does not work in preventive care because the number of patients is not based on sickness, but patients with a set of conditions. So, the physician needs to delegate more to the clinical staff.

The critical resource limiting the scalability of the acute care model is the physician at the center. In order to increase traffic, the clinic must increase the bandwidth for physicians by increasing the number of physicians. In the preventative model, care resource planning becomes the critical component, scaling to the care providers’ bandwidth. In order to expand the preventive care service, the clinic may increase lower-cost resources or simply outsource outreach activities to leaving the physician to handle escalated events, which result in appointments and visits.

Effective billing

Billing is not by appointment but based on time monitored. The amount of billing is based on the effectiveness of your system in maximizing your clinical staff’s bandwidth, which health care IT is transforming to either manual or passive. In the preventive care model, the ratio of patient care providers increases as the demand for workflow automation escalates. This need will be the next wave of health care IT solutions and will be the savior for care providers by maximizing their revenue from preventive care. It is a “must-have” as health care insurers are focusing more on preventive care.

2020: beyond health care IT

Health care IT is the enabler of preventive care delivery. Look at a simple case of remote patient monitoring in which data is collected from patient medical devices. Patients are required to “operate” the medical devices. The clinical staff helps patients set up device monitoring.

Health care IT can ease the data flow, ease the user experience, ensure secure data flow, but the operational model is required to inject more components in the workflow. So, as we begin to turn the calendar page to 2020, it is important that health care institutes prepare and not be disrupted.

David Conejo is CEO, Rehoboth McKinley Christian Health Care Services.

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