Historically, a MSO would deliver common business services designed to help provider practices with administrative burden or provide scale effect for managing overhead costs. As a result, the scope of a MSO’s service offerings would be narrow and cover offerings such as group purchasing, credentialing, office management or centralized billing services.
The additional objectives of a PHSO are three-fold:
These include moving the needle on quality measures and outcome performance, controlling total cost of care and providing improved patient access to medical care.
The goal is to improve patient loyalty and experience, ultimately keeping patients in an organized system of care. A PHSO also acts as an aggregator of key patient and administrative data so it might become the conduit for a transfer of knowledge critical to success in managing the health of populations.
Quality improvement initiatives must be grounded in a firm understanding of current performance by providers related to the key measures negotiated with managed care payers in a performance contract. Contracts that use shared savings, pay for performance, partial or capitated risk related to utilization and cost targets reward physicians and other providers only when specific measures can be calculated and action can be taken en-masse to have a positive impact on those measures.
Aggregating care delivery data across a network of participating providers is critical. A foundational capability of a PHSO must be deploying the information technology and analytics systems required to determine how care is currently delivered across a network. IT solutions that integrate claims-based data provide the first level of visibility regarding missing or over-utilized services. Such data could bring to light missing services and identify patients with complex or polychronic conditions who may benefit from additional care management.
Patient-centered care needs to augment this view of historical services with a forward-looking perspective to inform an individual plan of care. Care plans which truly engage patients will consolidate to the best extent possible, a whole-person view of the patient’s situation, integrating medical record data, diagnostic results, medications, procedures and clinical interventions into a longitudinal record. Each provider involved in caring for a patient needs to be able to see what other care is being provided to a patient in different care settings, and document the services they provided the patient, therefore, playing their role in furthering the objectives of a care plan.
Sound financial management of healthcare resources should be placed in the hands of clinicians; the historical adage regarding the power of the pen (i.e., a physician’s ability to prescribe, order services or procedures) is just as true and important today if healthcare costs are to be managed effectively.
The backbone of core services that a provider needs to manage healthcare costs must be informed by a holistic view of the cost associated with an individual’s care. In this context, the role of the PHSO is to present to the provider, at the point of care, key data elements to help ensure the best clinical decision is made for a patient, in the most cost-effective manner. A PHSO fills this role by pulling together data on care provided, aligning those elements to the patient’s care plan and then giving providers and patients relevant cost information to help support making the right decision.
Common examples of where integrating cost and clinical data points are essential if a provider hopes to serve the best interest of a patient and performance expectations of value-based contracting. They include forecasting an appropriate length of stay, understanding the appropriateness of prescribing a generic drug, preventing duplicative and expensiver diagnostic tests or directing a patient to a lower cost site of care, such as an ambulatory surgery or urgent care center.
The infrastructure developed through a PHSO should reflect current capability gaps of the providers to be served. The assessment of provider needs and existing methods to manage and report upon clinical and cost performance at network/ population and provider/patient levels serves as a baseline around which new common services should be developed.
In some organizations, understanding and providing visibility to the variability of how care is provided within a network now might be the most valuable information. For other organizations, the ability to stratify a population to identify those most in need of care management and care coordination might provide the best return. The unique needs of provider practices, hospitals and patients served by a network have to be the basis around which a PHSO’s infrastructure, staff, expertise, programs and technologies are scoped and designed over time.
The strategic vision for the infrastructure services should have a multi-year implementation and scalability plan to ensure financial investments are spread out and are prioritized based on goals of the network and its timing for moving into value-based payments for population health management.
