The enactment of the Patient Protection and Affordable Care Act of 20101 (PPACA) provides a mandate to revamp the U.S. health care delivery system—currently an array of uncoordinated and often costly services that largely treat disease events—to incorporate approaches aimed at preventing disease, coordinating care, and rationally reimbursing providers on the basis of quality processes and outcomes. The law directs the Department of Health and Human Services to establish a new office, the Center for Medicare and Medicaid Innovation (CMI), to identify new, cost-effective models of health care delivery and reimbursement and conduct large-scale demonstration projects to implement and evaluate them. By 2011, the Secretary of Health and Human Services will identify priorities for demonstration projects to “test innovative payment and service delivery models.”1 Preference will be given to models that improve coordination, quality, and efficiency.
PPACA marks the U.S. government's commitment to the widespread adoption of patient-centered approaches, coordinated models of care, and rational reimbursement. However, as is typical of legislation, it leaves critical components of desired delivery and reimbursement reform to administrative agencies to define and put into practice. Reforming health care to simultaneously decrease costs, improve quality, and change its focus from treatment of disease to prevention and continuity of care is a major challenge requiring innovation in education, research, and care delivery. This provides an important opportunity for academic health centers, which, through their core missions, can create the technologies and provide the practical knowledge needed for meaningful health care reform.
We propose that academic health centers lead health reform efforts by adopting personalized health planning, an approach that can provide both a clinical infrastructure to better coordinate patient-centered care and an effective means to collect and monitor data needed to support rational reimbursement. Personalized health planning focuses the orientation of the physician's “workup” on quantifying a patient's risk for disease or disease-related events, identifying strategies to track and minimize such risks, intervening effectively when needs occur, and engaging the patient in his or her care. This approach promotes personalized, predictive, preventive care and fosters meaningful patient engagement.2
PPACA and Care Improvement Strategies
PPACA's expansion of health insurance coverage depends on anticipated savings from changes in care delivery and payment reform. These savings are expected to come from initiatives aimed at reducing costs while improving care, such as alterations of current Medicare and Medicaid payment schedules to encourage cost-effectiveness, expansion of insurer reporting requirements to include health outcomes, and creation of demonstration projects and development grants to spur better models of care. PPACA authorizes several large Medicaid- and Medicare-based demonstration projects experimenting with novel health care delivery, community health improvement, and reimbursement models. By 2011, CMI will begin demonstration projects to explore non-fee-for-service reimbursement models, including global, episodic, and comprehensive or salary-based payment models. To stimulate change in the private sector, PPACA stipulates that, within two years, health insurance companies must publicly report whether they incorporate programs aimed at providing more cost-effective care, including quality metric reporting, effective case management, care coordination, and chronic disease management. PPACA also authorizes grants to develop community-based wellness initiatives, to design new methods to assess health care quality, and to extend existing gain-sharing demonstration projects that allow physicians to share the benefits of cost reduction.
Coordinated models of care
Coordinated models of care that align payments with desired outcomes have gained considerable traction as potential solutions to reduce costs and improve the quality of care.3–6 PPACA authorizes demonstration projects to explore different approaches to coordinate care; of these models, patient-centered medical homes, accountable care organizations, disease management programs, and health care innovation zones have garnered the most support among policy experts and professional organizations, including the Association of American Medical Colleges, the American Academy of Pediatrics, and the American College of Physicians.
Patient-centered medical homes emphasize the role of continuous primary care and provide each patient with a personal physician and a multidisciplinary team.3 Similarly, accountable care organizations aim to integrate patient care across various providers within a targeted service area. They stress shared responsibility for quality of care and cost among local hospitals and the multispecialty physicians who work in and around them. Medicare accountable care organization demonstration projects authorized by PPACA will be required to service the primary care needs of at least 5,000 beneficiaries. In contrast to the first two models, disease management programs coordinate care around specific chronic diseases, providing focused management for patients with conditions such as diabetes and heart disease.7 Finally, in health care innovation zones, teaching hospitals and community providers collaborate to develop comprehensive and more efficient health care delivery systems with aligned payment structures and to fund innovative methods for training clinicians. Academic health centers, with their strong capability for clinical innovation and their central role in research and training, are uniquely positioned to lead the development of these cost-effective models of service delivery.
Reimbursement of care
PPACA requires the implementation or pilot-testing of reimbursement models that provide financial incentives for decreased costs, adherence to quality standards, and improved outcomes. These models fall into several major categories: provider performance reports, pay for performance, best practice pricing, alignment of provider incentives, and bundled payment.8
Provider performance reports furnish patients with information about provider cost and quality to assist them in making informed health care choices. The pay for performance model rewards providers for meeting specific measures for quality and efficiency. PPACA mandates that Medicare will begin incorporating performance measures into payment schedules by 2013. Best practice pricing sets reimbursement rates based on the most cost-effective services and treatments, as measured by metrics such as readmission rates, medication error rates, patient compliance, and patient outcomes.
Alignment of provider incentives includes gain-sharing or shared savings plans, in which payers and providers share the savings realized through efficient performance. PPACA extends the existing gain-sharing demonstration projects initiated by the Deficit Reduction Act of 2005. Bundled payment, a single payment for a combination of different services, may be considered for a disease process (disease management), health care interaction (visit based), health event (episodic), or the entire patient over time (global or capitation). PPACA specifically authorizes demonstration projects evaluating both global and episodic payments where a single episode includes all care for an individual 3 days before and 30 days after a hospitalization, as well as post-acute follow-up.
Common challenges impeding coordination of care and reimbursement
PPACA proposes models of coordinated care and reimbursement that are designed to improve quality and cost-effectiveness. However, the models do not share a standardized approach to improve the care delivery process and to establish metrics for performance-based reimbursement. Such an approach is critical because research has shown that coordinated care models vary widely in how they deliver care.3,7 A recent study of primary care practices attempting to transition to the patient-centered medical home model attributed the inconsistencies among practices employing that model to a lack of standardized implementation plans.9 Further, the significant heterogeneity among care delivery features described in the literature prevented researchers from conducting a formal meta-analysis of the medical home model.3 Disease management programs also have extreme variability among individual care design features and program implementation plans.7 The inability to generalize across care delivery models makes health care reform more challenging. Yet perhaps the most serious deficiency of PPACA's proposed coordinated care models is the lack of a core, uniform process for approaching care at the level of the patient. Berenson and colleagues10 suggested that for models like the patient-centered medical home to be successful, processes must be developed to coordinate patients' care both within and outside practices, as well as to capture and use data to inform evidenced-based decision making and population-based performance evaluations.
Similarly, the main challenge facing rational reimbursement models is the lack of a uniform process to accurately assess the complexity of care needed, the quality of care given, and the outcomes attained. For reimbursement models to support cost-effective care, providers and payers must be able to adjust for risk and complexity, monitor adherence to practice standards, and evaluate health outcomes. PPACA requires federal administrative agencies to establish guidelines regarding evaluation of quality, standardized risk assessment, and further development of care quality metrics, but the law does not provide specific recommendations other than that data be collected electronically, preferably through the use of an electronic health record. Pay for performance, best practice pricing, bundled payment, and provider performance reports all require data collected at the individual patient level that can be aggregated at the patient population level to evaluate the health care process, including outcomes, quality measures, patient satisfaction, and health data.
Personalized Health Planning Enables Coordinated Care and Rational Reimbursement
In response to the common challenges facing coordination of care and reimbursement, we propose personalized health planning as the best method to foster both the delivery and the rational reimbursement of high-quality, cost-effective, patient-centered health care. Personalized health planning provides a core process or architecture around which other, more heterogeneous models of care can be unified.2 Indeed, PPACA's authorization of demonstration projects for “individualized wellness plans” in Medicare and community health centers provides an opportunity to adopt this approach.
The goal of personalized health planning is to engage patients with their providers in preventive, strategic health planning and care to enhance the patient's health, avoid the development of preventable disease, and minimize the impact of and coherently treat chronic disease if it develops.11,12 In collaboration with the patient, the provider develops a dynamic wellness and therapeutic plan (i.e., a personalized health plan) to identify needed activities and services and to establish a critical link between the provider and patient. To create the plan, the provider conducts a health risk assessment using the best known clinical risk factors for disease, including family history, physical findings, and results of laboratory and imaging tests, and, when appropriate, employs emerging technologies such as genomic testing, biomarkers, and multivariant risk models.13 If disease occurs, personalized health planning can serve as an effective management approach to quantify, track, and minimize disease-related risks, coordinate needed services, and maximize patient compliance.
Patient engagement is a critical facet of personalized health plans. Patients often want to be involved in decision making related to their health care,14,15 but they may not always be given the opportunity to participate effectively.10 Empowering patients to enhance their health or manage their chronic disease leads to improved functionality and quality of life and to decreased health care costs.16 When the personalized health plan is supported by a personalized electronic health record, the plan is portable and can provide guidance at multiple points of care.13 Such portability is especially critical when individuals move across health care delivery systems because of changes in insurance, employment, or location.
The concept of personalized health planning is well grounded in current understandings of disease development and provides a rational approach to personalize preventive patient care.11 It builds from the current focus on identifying and treating root causes of disease to recognizing that chronic diseases develop over time based on genetic inheritance and environmental exposure, that risks change over time, that progression toward disease can be measured and tracked, that disease events can often be anticipated and prevented, and that therapies can often be personalized. Importantly, emerging research has led to an explosion of new technologies enabling more refined health risk analysis, tracking of disease progression, and personalization of therapy.11,17,18
As personalized health planning is a relatively new concept, it is more a framework for an approach to care than a well-analyzed model. Nonetheless, early indications suggest that such planning brings together all of the major components of care known to best enhance cost-effectiveness, including coordination of services, prevention, patient engagement, organized data collection, and incorporation of state-of-the-art clinical approaches.2,5 PPACA recognizes this by expanding Medicare coverage to include annual personalized health planning visits which incorporate health risk assessment.
By integrating care at the level of the patient, the personalized health plan provides the architecture around which model delivery systems and associated reimbursement can be built. Personalized health planning can fulfill many of the PPACA mandates that the CMI must follow in evaluating new health care models. For example, personalized health plans feature regularly updated patient care plans that fit the needs of the individual, provide patient-centered care, coordinate care over time and across settings, and facilitate information sharing among providers, patients, and caregivers. Personalized health planning also supports performance-based models of reimbursement, including pay for performance, best practice pricing, and provider performance reports. It can provide individualized, risk-adjusted patient data to be analyzed globally for patient population features, expected expenditures, and outcomes for specific disease events or global health and wellness goals. Under a shared savings plan, personalized health planning can provide risk adjustment data that, when aggregated at the level of the patient population, can be used to establish rates for expenditures. Similarly, data from personalized health plans can be used to develop risk-adjusted payment models for capitated reimbursement. Importantly, personalized health planning complements any model of delivery or reimbursement and can enhance proposals to improve quality and reduce costs.
Personalized Health Planning in Academic Health Centers
We believe that developing and adopting personalized health planning offers academic medicine a major opportunity to lead health care reform efforts. As the current, fee-for-service reimbursement landscape changes, health care organizations must revisit their existing business models to remain sustainable. This is particularly true of academic health centers, which may be at increased risk due to the high consumption of health care resources that accompanies medical training, the high complexity of the patients served, and the preponderance of specialists and cutting-edge technologies employed.19–21 Given that clinical revenue is a dominant source of academic health center funding, these centers must adapt quickly to remain viable during times of major changes in access and reimbursement.19
Fortunately, PPACA provides substantial opportunities for academic health centers to capitalize on their strengths as leaders in research, education, and clinical innovation by developing and adopting more efficient models of care. By using their research and clinical expertise and collaborating with surrounding providers, most academic health centers can create accountable care organizations and health care innovation zones to provide better care to their communities.20 Academic health centers could differentiate themselves from other health care providers by developing and using personalized health planning as their core approach to improve and coordinate patient care. Academic health centers' core missions and unique strengths will allow them to adapt and continually improve this innovative model of care, making it practical to apply broadly. They will thereby transform care while ensuring their viability.
PPACA demands the development and adoption of new approaches to coordinated care and rational reimbursement, but administrative agencies will determine the means that can best accomplish these goals. Personalized health planning is a clinical approach that links coordination of service delivery and provider payment reform with better patient care. It provides a means to create strategic, personalized, and preventive approaches while gathering important data needed to create value-based reimbursement for care. We believe the development of personalized health planning for broad clinical use is a major opportunity for academic health centers. Their resources can provide the research, education, clinical know-how, and delivery capabilities for adoption and continued improvement of the model. PPACA provides academic health centers with the resources and opportunities they will need to do this, thereby allowing them to lead meaningful health care reform.
The authors gratefully acknowledge the invaluable assistance of Cindy Mitchell (Duke University Medical Center) in editing the manuscript.
Dr. Ralph Snyderman is founder and chairman of Proventys, Inc, and serves on the board of directors of XDx, Inc.
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