Co-Management

How to Transition Successfully to Value-Driven Healthcare

By James E. Grue, OD,
Ronald P. Snyder, OD, FAAO,
Michael J. Lipson, OD, FAAO, FSLS

Jan. 5, 2022

Value-driven healthcare is good for patients, good for our healthcare system, and, ultimately, good for eyecare practices. But first you have to successfully make the transition to this approach to delivering care.

This is the last article in our series on Empowering the Patient. The previous four articles have covered individual aspects of the process. This article describes how it all comes together. This article will again use the example of a diabetic patient without retinopathy who is in your office for their annual dilated eye exam.

The process of transitioning the U.S. healthcare system is being driven by a combination of factors, the enactment of the 21st Century Cures Act and changes in reimbursement guidelines under the new 2021 CMS billing guidelines. The fundamental concept behind these legislative changes is that the best care is ultimately the least expensive care. The approach is based on ensuring providers are delivering the best possible care while looking at every possible way to reduce the cost of delivering that care without compromising quality. The easiest way to understand the value of outcome analytics is to look at how providers respond when challenged to “deliver the best care possible.”

A New Way to Approach Care
Providers who do not use a registry struggle with how to accomplish that goal. In fact, providers delivering traditional eyecare are often quoted as saying that it is difficult, or even impossible, to define and understand “quality.” The reason this is a difficult concept is because the approach to traditional delivery of care is very “doctor-centered.”

At the completion of diabetic annual exam, if the provider determines that there is no retinopathy, nor any other conditions that need to be addressed, the explanation to the patient includes everything the provider thinks the patient needs to know. A provider delivering this type of care has followed all available evidence-based guidelines, told the patient the results of the exam and has also told the patient everything their training and experience indicate that the patient needs to know. It is reasonable for this provider to assume their patients are getting the best outcomes possible. It is also easy to see why it is a challenge for them to see what they can change to get better results.

Let’s look at how the provider who has outcome analytics responds to “deliver the best care possible.” This provider has outcome analytics that are tracking the change in HbA1c over multiple visits. It is well established through evidence-based medicine that the higher the HbA1c, the higher the risk of developing retinopathy and developing systemic complications from diabetes. The new CMS coding guidelines reimburse at a higher rate when “risk” is identified and addressed during the exam. That makes tracking the HbA1c an important analytic. It is important to understand that this provider was doing exactly what the provider delivering traditional care was doing before they had the analytics. The difference is that the provider using outcome analytics now has additional data assessing risk to increase the value of that encounter.

When a provider signs up for a registry, the initial data typically covers patients seen over the previous two years as previous data can be extracted from the electronic health record database. So, even though the provider was reporting to the patient everything they thought the patient needed to know, additional data is now useful to report on all diabetic patients in this practice. For example, below is a report on how HbA1c changed between the previous exam and most recent exam for all diabetic patients in the practice over the previous two years:

1) 52 percent have an increased HbA1c
2) 28 percent of patients have had no significant change
3) 20 percent have a lower HbA1c

This high-level analytic seems to indicate that there is a huge opportunity to get better outcomes. It seems reasonable to expect our exams should help the patient reduce their risk of developing retinopathy, rather than increasing the risk. In fact, one of the best evidence-based studies shows that if the HbA1c is lowered from an average of 9 down to 7 over a 10-year time period, the amount of retinopathy is reduced by over 50 percent. The AOA updated guidelines on the management of diabetes cites this study as an important piece of evidence-based literature that should be driving clinical care.

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Additional analytics, which this provider has available through the registry, offer a breakdown of these numbers even further into “populations.” For example, the data shows that for patients who had an HbA1c between 7.0 – 7.4 at their previous exam, 70 percent have a higher HbA1c at their current exam. By the way, these numbers are not made up for this article. They are representative of actual registry findings.

How is this Data Used?
The comparison data available in the registry shows this provider those other offices have been able to reduce the number of patients that have an increase in HbA1c in this population to as low as 25 percent, instead of 70 percent. It turns out that for this population of patients that have an HbA1c between 7.0 – 7.4, how you tell them they don’t have retinopathy has a dramatic effect on that patient’s understanding of their condition and ends up significantly affecting the analytics and the patient’s risk of developing retinopathy.

The key to improving the data is to incorporate a patient-centered approach to improving the analytics. Previous articles in this series discussed the two questions that you need to ask the patient. This is where the answer to those two questions will give you, the provider, the key to getting better outcomes. If the analytics show that 18 percent of patients, who had an HbA1c of  7.0 – 7.4 at their last exam, now have an HbA1c of  8.0 – 8.4 at their current exam, that is a population where improvement is clearly possible. The answers the patient gives to those two questions will tell the provider exactly what needs to occur in the plan to help the patient overcome the obstacles they are facing.

For providers who have these analytics, everything that was previously confusing about the transition to value-driven care, now makes sense:
1) The key is understanding how the patient thinks, not the doctor, about their care and the decisions the patient makes on a daily basis that drive the outcomes. That is the reason this series is called “Empowering the Patient.” Patient involvement is the single most important thing that analytics will accomplish in managing chronic conditions. The previous articles discussed two questions that patients must be asked to better understand what they need to know to make better decisions on a daily basis in managing their condition.

2) These providers now understand why the 21st Century Cures Act has such an emphasis on interoperability and eliminating information blocking. They now see that to get the ideal reduction in HbA1c, a team effort is required to coordinate how their office interacts with the patient and with the rest of the patient’s care team.

3) They also understand that the analytics are what is going to drive the clinical decisions they make and provides a way to assess how effective those decisions are in improving outcomes.

4) They also understand why CMS changed the coding guidelines for 99XXX billing codes as they realize that providers who identify and address this level of risk should receive higher reimbursements than those who don’t.

5) They also see how delivering outcome-based care driven by analytics opens huge opportunities to interact differently with the rest of the healthcare providers in the local community. This also positions their practices as those that primary care physicians want providing eyecare to their patients with diabetes.

6) The process of using analytics to negotiate higher reimbursements from payers now makes complete sense. They see how the “alternate payments,” which many other healthcare providers enjoy, is possible for eyecare as well.

Summary
In summary, using a registry to analyze clinical outcomes is not just a check-mark step in the process of transitioning to outcome-based care. It is the key to the transition. Outcome analytics are what make everything in the process come together and make sense. Analytics change virtually everything in a practice.

Analytics are changing the culture of healthcare. Traditional healthcare delivery evolved under the restrictions of paper records and communications that required that a human being read everything shared between providers. Analytics drive a delivery of care that uses the power of big data and electronic communications to allow us as providers to deliver a level of care that wasn’t possible previously. It doesn’t matter whether you are managing diabetes, dry eye or myopia, the analytics available through registries drive the new outcome-based approach to the delivery of care.

James E. Grue, OD, is a health-care reform speaker and consultant. To contact him: JimGrue@HealthCareRegistries.com

 

 

 

Ronald P. Snyder, OD, FAAO, is the president and CEO of HealthCare Registries, LLC. To contact him: RonSnyder@HealthCareRegistries.com

 

 

Michael J. Lipson, OD, FAAO, is the chairman of the OrthoK Advisory Panel of HealthCare Registries, LLC.

 

 

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