How population health management solutions are helping Medicare and Medicaid grow old gracefully
With Medicare and Medicaid recently celebrating 50 years of existence, it’s fascinating to see the parallels between these two programs and the passage and implementation of the Affordable Care Act (ACA) in 2010. Similar to the ACA, the enactment of the Social Security Amendments of 1965, which created Medicare and Medicaid, caused a certain amount of consternation among those who believed it was going too far toward creating an unaffordable social welfare state. Many people have similar concerns today about the ACA. Regardless, few could argue that, for better or worse, Medicare and Medicaid have become an enormous part of our societal fabric and a core characteristic of the American identity.
But like all high-value, complex programs, Medicare and Medicaid haven’t reached the half-century milestone without suffering from a few ailments along the way. When the programs were established during the Johnson administration, the primary focus was to provide access to affordable medical insurance to the elderly, disabled, and poor. There wasn’t a great deal of focus on the quality, service, efficiency, or overall value of care delivery and there was no attempt to rethink the traditional fee-for-service (some say fee-for-volume) reimbursement methodology embedded in our American system. This oversight has taken its toll over the years and is something that, to a certain extent, the ACA seeks to correct.
Today, the fee-for-service approach that rewards providers for volume of services delivered is being replaced by new reimbursement models that focus on quality, efficiency, and cost effectiveness. The Centers for Medicare and Medicaid Services (CMS) now issues sets of performance metrics with minimum performance thresholds to maintain licensure (for example, Medicare Advantage plans) or to qualify for shared savings. This is done to encourage payers and providers to begin to working collaboratively to improve the health of a population and the experience of care while ‘bending the cost curve’. These goals form the basis of the Triple Aim and help define what is meant by ‘value-based care’.
Achieving success with all three goals of the Triple Aim creates a high-stakes environment for all participants.
Enter technology. Health IT systems, particularly those that facilitate comprehensive population health management (PHM) programs, are being viewed as the conduit through which healthcare organizations can ensure compliance with CMS mandates and other regulations as they transition to value-based care models and participate in shared-risk programs with other entities in their communities.
An effective PHM technology must provide healthcare organizations – payers, providers, and all others – with all of the tools and resources they need to optimally manage the health of each and every one of their patients while also improving the health status of the whole population they serve. This means gathering patient data from disparate sources into a central location, applying sophisticated analytics to understand which patients require attention and in what way, and sharing that information to peer stakeholders with supportive workflows so they can do their work efficiently. In essence, technology must enable stakeholders to view an entire patient population and determine where to best focus limited resources while still supporting the entire group as a whole.
At ZeOmega, we believe this requires an inclusive and holistic approach that is built on five essential components, or pillars, which my colleague Nandini Rangaswamy very effectively detailed in a blog series earlier this year.
Medicare and Medicaid have forever altered the way healthcare is managed and delivered in our country and, for that, they deserve a tip of the hat on their 50th birthday. As we move forward, ZeOmega is extremely proud to be at the forefront of innovation to ensure they remain strong and effective for the people who need them most.