The Gap in Managed Care Technology

By Jose M Sanchez, CIO, Miami Beach Medical Group

Jose M Sanchez, CIO, Miami Beach Medical Group

The emergence of every new healthcare reimbursement model usually comes with the creation of a newer technology that meets or surpasses its needs. There are groups of sharp, new vendors eager to sell the latest in software and its accompanying gadgetry. Healthcare, in general, has been no different; with hundreds of vendors offering all types of solutions ranging from patient-centric devices such as Patient Kiosks and Home Health Monitoring devices to the latest “middleware” which promises to get all your systems “talking” to one another. Not to mention the boom of Electronic Health Records (EHRs) which help healthcare providers document and record all types of patient data. With so many solutions available, one would think that software for managing “managed-care” or “performance-based” reimbursements would be plentiful. However one would be wrong.

Let us start our discussion with answering the simple question of: “Don’t EHRs take care of this?” EHRs are, for the most part, an exponential improvement over the archaic paper-based method of record keeping previously used. They provide standardized documentation; coding and can even measure a provider's ability to use the technology “meaningfully”. As a matter of fact, government regulations are currently set for a standard “Meaningful Use” criteria broken into stages. In theory, providers who achieve “meaningful use” can use standardized reporting and functionality to better manage and care for their patients. Depending on who you ask, EHRs range from glorified word processors, to complex database systems created for the IT world. The truth is that many small to mid office provider struggle to make sense of more data than they have ever seen yet give patients the personal touch they expect and have grown accustomed to. Most professionals would agree that EHRs serve as great tool for capturing information and for reporting. But how about managing the patient population itself?

The “managed care” or “performance-based” reimbursement model (also known as “HMO” or “Risk based” systems) is at its core a very simple concept. It is usually found in having a Payer (i.e. Insurance company) reimburse or fund a provider to oversee a population of patients. The provider is required to manage a group of patients for a set of monetary amount (usually “per patient per month”), regardless of how many times a patient gets seen. It promotes better care by encouraging providers to actively follow up on patient health through preventative medicine (i.e. mammograms, routine lab work, etc) and in return keeping patients healthier. A healthier patient population is a much more cost-effective population and one in which healthcare costs are easier to manage and predict.

So why do EHRs fall short? The answer is in the fact that EHRs focus on the provider-patient experience and not the patient population itself. Additionally, health care cost and performance metrics are usually not included or calculated when showing “dashboards” or reports. EHRs are great for showing providers how many patients are missing mammograms but lack on the ability to manage this over a group. Take the following as an example:

Patient A:

Female patient that has been admitted to the hospital 4 times for Flu-like symptoms in the past 60 days. She is missing her mammogram. She is in danger of reaching their max Rx benefits due to mostly Brand name medications being dispensed and complains constantly about the office not opening on Friday afternoons. She is also due for their flu-vaccine.

EHRs are great for showing providers how many patients are missing mammograms but lack on the ability to manage this over a group

Patient B:

Female patient missing mammogram

One would argue correctly that Patient A is considerably more at risk for health issues and requires more patient service from the provider and their staff. However, 99 percent of EHRs will not report on this fact and will offer no way of bringing this information to light. The reason is that EHRs are designed for clinical capture. Most do not include any type of CRM (Client- Relationship-Management) type functionality for capturing complaints from patients or to tell you which patients have been recently added to your practice (and which one has left). Additionally, performance metrics such as Generic Drug Utilization is not taken into consideration. Systems are more concerned with creating medical claims than they are reading and extrapolating the information sent to them. On the flip side, most Payer (Insurance) systems which are set up to manage credentialing, dispense ratios, and utilization are not usable for the provider since they are more interested in reading from the claim rather than capturing the information that goes into them.

The GAP is ultimately created for providers who need both functionalities while keeping their patients healthy and practices profitable. While there has been a recent surge in “reporting” systems to help these types of providers, these systems have a long way to go, with most being nothing more than advanced “readers” of the large data reports provided back from Insurance companies.

The right solution will be one which marries both worlds without creating a data nightmare for the provider. It must include the ability to report and measure the performance metrics used by Insurance companies and CMS while also allowing for interoperability with the current EHR marketplace. Those vendors who choose to focus on this gap face a formidable challenge yet hold the key to bridging the gap which ultimately may be financial head-turner this industry so badly needs. Let’s see who is up to the challenge.