Last month, my colleague Monica E. Oss, took a look at a proposed initiative by the Centers for Medicare and Medicaid Services (CMS) for direct value-based reimbursement of provider organizations, describing it as “another step in moving health care provider reimbursement from volume to value” (see VBR Jumping From Hospital-Centric ACOs To Community-Based Players). What caught my interest was the focus on consumer-centricity: “The proposed model touts a consumer-centric model, by giving consumers greater control in selecting their primary care practice through beneficiary engagement tools to empower beneficiaries, their families, and their caregivers to take ownership of the beneficiary’s health.”
Start a discussion about the benefits of consumer-centric health care at your local coffee shop and you likely won’t find anyone who disagrees with the idea. We live in a crowd sourced, “everything ratable” society—think Yelp, Uber, Glassdoor, etc. We all want five-star service, and if we don’t get things the way we want, we expect the vendor of our service (be that Grubhub delivery or our primary care doctor) to make it right.
There are consumer-centric strategies and models on the drawing board all around the field. Or, as Geisinger Health System’s Chief Informatics Officer Alistair Erskine was quoted as saying in a Forbes article last October, “Everyone talks about putting the patient first and that’s great, but to make it actually happen we needed to take a big step that would force us to change” (see The New Healthcare Imperative: Building A Consumer-Centric Culture). Geisinger’s “big step” was to offer refunds on copayments in 2015 as part of its ProvenExperience program. Geisinger now provides copayment refunds on certain types of services to consumers who are unsatisfied with their care (see Would You Give A Refund To Dissatisfied Consumers?). In 2016, ProvenExperience refunded $320,141; in 2017, it refunded $411,325; and as of March of 2018, it has refunded $266,340 (see Steal This Idea: Geisinger CEO David Feinberg Explains How Giving Back Money Is His System’s Most Valuable Expense).
More recently, I had the chance to hear Charles Gross, Ph.D., Vice President, Behavioral Health, Anthem, Inc. share Anthem’s value-based reimbursement model for contracting specialty care during his opening plenary address, Going Beyond Innovation-Developing Partnerships With Health Plans at The 2018 OPEN MINDS Strategy & Innovation Institute. He was quick to point out that a core element of Anthem’s VBR strategy was a great consumer experience. This perspective isn’t limited to Anthem. We’ve seen similar focus on consumer experience as an element of “value” by Wellcare (see Getting Past The Bumps In The Road To Value-Based Reimbursement); Optum (see Developing A Value-Based Partnership: The Optum Case Study); and Magellan (see ‘A Commercial Health Plan’s Perspective’: Magellan’s Philosophy & Approach To Value Based Payment Arrangements).
But the sad reality is that even with these health plan preferences for a great consumer experience, most of the consumers needing more complex care and support don’t really have selection preference, nor family members that can help them guide their choices. My experience is that Medicaid consumers typically end up with whomever the direct support professional (DSP) chooses. While these DSP choices are based on good intentions and consumer convenience, this situation actually defeats the idea of consumer-centricity.
What I’ve seen in practice in the field is that Medicaid consumers are not routinely asked what services they want, nor how they would like to receive them. Be it good intentions, staff shortages, limits in coverage, or a host of other reasons, these consumers typically get what they are given, not what they necessarily want nor need.
What does it take to have a “consumer centric” system? How do managers of provider organizations improve this situation in real time? How do they perform better on value-based contracts? I think it has to start from the bottom up. Unfortunately, the DSPs who spend the most time with consumers—particularly consumers with complex needs—are proving harder to keep on the job. The average turnover rate among all health care workers was 20.6% in 2017, up dramatically from 15.6% in 2010 (see High Turnover, The Other Staffing Issue). In this kind of high-turnover environment, executive teams need to ask:
- How skilled are the DSPs?
- Are staff trained to see the nuances in the consumers to whom they provide care?
- Is there consistency in staffing to allow for rapport and relationship building with consumers?
If we flipped the script and began to give complex consumers more choice and control of their care, I imagine we’d find less friction with direct care staff, which would likely translate to a happier work environment and reduced turnover (not to mention better health care outcomes).
The overarching issue, specifically for consumers with behavioral health conditions, is the blurred line between “primary care concerns” and “psychiatric concerns.” Care coordinators often visit consumers who have symptoms that could fit in any bucket—for example, are the stomach pains a side effect of a new depression medication, an effect of a poor diet, or symptoms of an ulcer? To make matters more complex, it’s not uncommon for the symptom to be the psychosocial result of loneliness. Isolation and loneliness are common for consumers in the complex care space (see Is Loneliness The Overlooked Social Determinant?). The current trend toward a more “whole person” approach to care coordination is positive. However, if you leave primary care and behavioral health treatment fragmented, you are missing the interconnection between body, mind, and social determinants.
I think the big question is how to develop—and retain—the DSP workforce, and how to provide that workforce with the care coordination tools they need. All roads in health and human services are leading to an integrated, community-based service system, but we need the talent to get us there.
For more on building and retaining an effective team, mark your calendar now for The 2018 OPEN MINDS Executive Leadership Retreat, taking place September 18-20 in Gettysburg, Pennsylvania. And be sure to check out my session, “Building The Management Pipeline: Identifying & Growing Future Leaders.”