Navigating the Future of Value-Based Care: Insights from Theresa Hush, CEO and Co-Founder of Roji Health Intelligence
In the rapidly evolving landscape of healthcare, Accountable Care Organizations (ACOs) are at a critical juncture. As leaders in the Value-Based payment models, ACOs face mounting pressure to generate significant cost savings for Medicare patient care. With discussions of budget cuts for Medicare resurfacing amid political pressures to reduce government spending, the urgency for ACOs to adapt and innovate has never been greater. At the forefront of this transformation is Theresa Hush, CEO and Co-Founder of Roji Health Intelligence, whose vision and expertise are shaping the future of healthcare analytics and cost management.
The Current State of ACOs in Medicare
ACOs have been tasked with the dual challenge of improving patient outcomes while simultaneously reducing costs. However, the reality is stark: ACOs collectively generated approximately $10.5 billion in savings in 2022, which, while significant, represents only a little over 1% of the staggering $944.3 billion in total Medicare spending. This raises a critical question: why are ACOs struggling to achieve deeper savings?
The answer lies in the complexity of healthcare costs. Many ACOs have relied on basic population health strategies, such as reducing hospital admissions and emergency room visits. While these approaches have yielded some savings, they often target low-hanging fruit and fail to address the more intricate factors driving healthcare costs. As Hush emphasizes, the path to meaningful cost reduction requires a sophisticated understanding of the underlying data and a strategic approach to patient care.
The Challenge of Cost Control in Value-Based Care
Cost control in healthcare is often misunderstood. The prevailing notion that cutting costs invariably harms patients has its roots in past experiences with prior authorization and benefit cuts. However, Hush argues that effective cost management can enhance patient care by improving coordination and addressing the hidden drivers of healthcare expenses.
Many ACOs have overlooked the significant costs associated with specialty care diagnostics and treatment, often viewing them as outside their purview. This oversight can lead to missed opportunities for savings. Moreover, the traditional reliance on retrospective claims data has limited ACOs’ ability to identify high-risk patients and implement targeted interventions. As Hush points out, without access to comprehensive clinical data, ACOs cannot fully understand the factors contributing to cost variation.
The Role of Data in Driving Change
In recent years, the Centers for Medicare & Medicaid Services (CMS) has introduced new requirements aimed at enhancing data aggregation among ACOs. The transition to Advanced Alternative Payment Models (APP) reporting and the push for Certified Electronic Health Records (EHRs) are pivotal steps in this direction. These changes will empower ACOs to harness clinical data from participating physician groups, enabling them to pursue more effective cost control strategies.
Hush believes that the future of ACOs hinges on their ability to leverage data effectively. By integrating clinical and claims data, ACOs can develop a clearer picture of patient care costs and identify the drivers behind them. This data-driven approach will allow ACOs to implement targeted interventions and improve patient outcomes, ultimately leading to greater cost savings.
Developing a Strategic Map for Cost Control
To thrive in the evolving landscape of value-based care, ACOs must develop a comprehensive strategic map for cost control. This involves linking quality and patient treatment to cost consequences, a task that can be daunting for organizations new to EHR data. Hush emphasizes the importance of understanding data quality, identifying gaps, and prioritizing both patient and organizational needs.
Technology will play a crucial role in this endeavor. ACOs need to seek out analytics and data aggregation vendors with specific clinical expertise to build comparable units of cost measurement. By focusing on episodes of care—conditions, treatments, and procedures—ACOs can target interventions more effectively and drive down costs.
The Path Forward for ACOs
As the healthcare landscape continues to shift towards value-based payment models, ACOs must rise to the occasion. The looming threat of Medicare budget cuts necessitates a proactive approach to generating significant cost savings while maintaining high standards of patient care. Hush’s insights underscore the importance of leveraging clinical data, improving patient engagement, and addressing hidden cost drivers.
In conclusion, the journey toward effective cost control in value-based care is complex but achievable. By embracing data aggregation and developing strategic approaches to patient care, ACOs can secure their place in the future of Medicare. With leaders like Theresa Hush at the helm, the potential for innovation and improvement in healthcare delivery is immense.
About Theresa Hush
Theresa Hush is a seasoned healthcare strategist and change expert, currently serving as the CEO and Co-Founder of Roji Health Intelligence. With extensive experience across the public, non-profit, and private sectors, Hush is dedicated to transforming healthcare through data-driven insights and innovative solutions. Her leadership is instrumental in guiding ACOs toward a more sustainable and effective future in value-based care.