Innovation Nation July 12, 2012 Presented by Kathryn Alexandrei. Overview. Understanding what is meant by innovation in behavioral healthcare Developing an Innovation Framework Becoming conversant with new models like Accountable Care Organizations (ACOs)
July 12, 2012
Presented by Kathryn Alexandrei
Understanding what is meant by innovation in behavioral healthcare
Developing an Innovation Framework
Becoming conversant with new models like Accountable Care Organizations (ACOs)
Next Steps – Your Innovation Cycle
R & D
Skills and Abilities
Sustaining Innovations (correction ribbon, lighted refrigerator, bucket seats)
allow you to make incremental changes in order to do what you’ve been doing more efficiently
or to produce a better outcome doing it.
Also allows you to maintain market share.
Disruptive Innovations (NetFlix, Craigslist, Amazon)
fostered by outsiders who want to upend markets and the way things are done
totally transforming the business model
Technology simplifies what had previously been complicated and cumbersome
Lower-cost financial model
Value Network is economically coherent (mutually reinforcing)
Source: Clayton Christensen
Solution Shop – expertise to diagnose and solve problems (you, lawyers, consultants). Charge for cost of expert time. Focus on diagnosis.
Value-Add Process – assembling solutions of higher value (retailers, auto-makers). Charge for value of assembled products and services. Focus on treatment after diagnosis.
Facilitated Networks – models wherein people exchange things with one another (insurance, mutual funds, eBay and WebMD are examples). WebMD has begun building communities of people with certain chronic conditions like diabetes. These models harness vast amounts of data and technology architecture.
Source: C. Christensen
Reforming health care financing (pricing, premiums, policies, coinsurance, financial eligibility, FFS, capitation, episode and case rates, etc.)
Health information technology (EMR, HIE, MU, PHR, etc.)
Internet and facilitated networks
Pharmaceuticals and medical devices
Medical education (behavioral medicine)
Retail (Minute-Clinics, Wal-Mart)
Personal Spending Accounts (debit cards)
Hospital and Provider Cost & Quality Comparisons online
Personal Health Records (PHR)
Coverage, Treatment and Cost Advisors
Health Risk Assessments with Incentives ($)
Disease Management Programs
Choice of Networks
Exclusive Provider Networks
Prevention Benefits and Services
Accountable Care Organizations
Patient-Centered Medical Homes
Value-Based Insurance Design (VBID)
1. Administrative Mandates (HIPAA 5010, ICD-10, etc.)
2. Care Management, Data Analytics, and Informatics.
3. Health Insurance Exchanges and Individual Markets.
4. New Provider Payment & Delivery Systems (ACOs, PCMHs, etc.)
5. Bending the Cost Curve.
6. Medicare and Medicaid.
7. Health Information Exchanges and EMRs.
8. Consumer's Role in the Modernization of Healthcare (social networking, incentives, CDHP, etc.)
9. Reform Uncertainties.
10.Payer / Provider Interoperability.
(Source: Managed Care Executives Group, March, 2011)
What is Desirable?
What is Possible?
What is Viable?
Patient Protection and Affordable Care Act (ACA)
Go Live 2014
Expanded Health Insurance Coverage - 2014
Market Results of Coverage Expansion
Source: Congressional Budget Office (CBO)
Impact of Affordable Care Act
Focus on coordination between primary care and specialty care:
Implications For States & Providers
Managing Multiple Chronic Conditions (MCC)
Educating the Public
Medication Assisted Treatment
Accountable Care Organizations (ACO)
Patient-Centered Medical Home and Health Home Models (PCMH) – Focus on Primary Care Integration
Value-Based Insurance Design (VBID) Promoting Evidence-Based Practices (EBPs) with Lower Coinsurance When Patients See Higher Performing Providers
“Blending and Braiding” Systems of Care
Joint Ventures and Affiliations
What is an Accountable Care Organization (ACO)?
A group that would include a hospital, primary care physicians, specialists, and possibly others involved in coordinating care for shared (Medicare, Medicaid, or other insurance) patients.
The ACO's goal would be to ensure that the care provided meets or exceeds quality benchmarks within the fee-for-service structure.
ACO members would share in resulting cost savings.
Use Lower Cost
Hospitals & Specialists
ER Visits &
Testing & Referrals
Revised Capitation (Global Payment Systems or Comprehensive Care Payment Systems)
Episode of Care Payment System
ACOs must develop a process for:
identifying patients who have complex needs (multiple chronic conditions)
or those who are at high risk of developing such needs
and provide them with wellness and prevention programs,
and complex case management, as needed
ACOs must make available or support providers’ use of electronic prescribing, electronic health records systems, registries, and self-management tools
Financial Infrastructure – Ability to track performance and payments
Reporting Infrastructure – Interface with Case Managers, Primary Care, and Care Coordinators
Performance Management – Access to disease-specific dashboards, baselines, benchmarks and adherence to best practices
Data Aggregation – Data warehouse, clinical decision support, and disease registry capabilities
Health Information Exchange – Interoperability and Meaningful Use
Information Technology Components
Data Analytics and Predictive Modeling
Disease and Case Management Software Applications
Enable your organization for change
Develop a strategic plan, business plan, and *especially* a marketing plan that enables innovation based on knowledge of market forces and market structural changes
Commit capital, develop a budget, and/or find investors or partners if you need them
Address staffing and the need for periodic expertise where innovation is concerned
Align innovation with your IT plans
Commit to Performance Mgmt framework
Manage your organization through change
Executives set the course and the mood
Establish and measure your expectations
Keep distractions and competing priorities to a minimum
Hold people (including yourselves) accountable
Align efforts so time and energy are not wasted
Provide reinforcements, encouragement and rewards (recognition)
Manage your organization through change
Become Learning Organizations (there is a lot to learn!)
Recruit, retain and train the right people in administrative as well as clinical areas
Leverage your Core Competencies
Encourage some risk-taking, experimentation and tolerate mistakes. Ask “What if…?”ALOT
Conduct market research – what you don’t know can hurt you
Invest in your brand image and dress the part of innovator
Use thoughtful scenario-based business modeling and business case methods to pilot your innovations
AHP Healthcare Solutions