© Springer International Publishing Switzerland 2016
Lewis A. Hassell, Michael L. Talbert and Jane Pine Wood (eds.)Pathology Practice Management10.1007/978-3-319-22954-6_22. Trends Towards Outcomes, Accountable Care, and Value-Based Purchasing
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Health Administration and Policy, College of Public Health, University of Oklahoma Health Sciences Center, 801 N.E. 13th St., CHB 128B, Oklahoma City, OK 73104, USA
Keywords
Centers for Medicare and Medicaid ServicesPatient Protection and Affordable Care ActHealth-care spendingAccountable Care OrganizationOutcomesValue-based purchasingMedicare trust fundMedicare Prescription Drug, Improvement, and Modernization ActTax Relief and Health Care Act of 2006ConsumerismPQRSTransparencySustainable growth rateMerit-based incentive payment systemMedicare Access and CHIP Reauthorization Act of 2015Value-based payment modifierBundled paymentsMedicare Shared Savings ProgramFee-for-serviceCapitationNarrow networksCase: A Glimpse into the Future
Dr. Lucy Yu, chair of pathology at Mid-State University Medical Center, felt a sudden sense of fear as she stopped to consider the big picture. As chair of the faculty practice plan’s finance committee, which oversaw contracts and finances for the nearly 600-strong group, she had been so focused on the execution of the meeting that she had not fully realized the discussion’s potential impact on her department. The committee was meeting with the state’s Medicaid Chief Medical Officer (CMO) to discuss a proposal to intensely manage congestive heart failure patients and diabetics with the goal of reducing hospitalizations and ultimately total care expenditures for these chronically ill patients. The CMO promised to fund several case managers and provide IT support with the potential additional gain to the practice of sharing half of any savings over projected expenditures for these patients.
Dr. Yu and the committee were excited at the potential savings but were even more interested in gaining experience with intensive case management for chronically ill patients. But as Dr. Yu reveled in the possibilities, it suddenly occurred to her: but what about pathology? How do we fit in this model?
Discussion: Two related trends are evident in this scenario: (1) the move to manage patients outside the hospital with the goal of keeping them healthy rather than waiting until acute care is needed, (2) delivering less acute care and reducing unnecessary care. Although, in some cases, more intense or frequent testing may facilitate managing patients outside the hospital, both trends otherwise run counter to how most pathologists have positioned their practices. Pathologists have thrived for years by doing testing, and more testing was generally better. While adapting to less testing is relatively straightforward, how to use our expertise to help manage patients at home and to improve the health of populations are areas in which few pathologists have had much experience. As the health-care system continues to move towards maintaining health in addition to mitigating sickness, pathologists must take on new roles. Will we bring our IT expertise to bear and provide seamless reporting across all environments? Can we design testing algorithms that focus on maintaining health? Or will we have a very limited role in the outpatient and even “pre-outpatient” (home) environments?
Transformation of the US health-care system and payment models was inevitable. In 2013, US health-care spending reached $2.9 trillion annually, approaching 18 % of the gross domestic product. Prior to passage of the Affordable Care Act, it was widely acknowledged that the Medicare Trust fund would enter deficit spending by approximately 2017. At the same time, there was growing consumer recognition that the costs of health insurance and the amount of out-of-pocket co-pays and deductible payments were outpacing rates of wage growth. The ever-increasing expenditures on health care in the USA were not sustainable and reports from the Institute of Medicine (http://resources.iom.edu/widgets/vsrt/healthcare-waste.html) highlighted that up to 30 % of health-care spending is wasted on things such as unnecessary clinical services, excessive administrative costs, inefficiently delivered services, prices that are too high, fraud, and missed prevention opportunities.
Besides the rising costs of health care, there was also broad recognition that there were widespread gaps in the quality of health care. Many studies demonstrated significant variations between providers of care on a host of quality metrics including process of care measures and outcome measures. Although the USA has the most expensive health-care system in the world, we rank last on indicators of efficiency, equity, and outcomes as compared to other industrialized nations (http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror). While the USA has developed the best “sick care” system in the world with a focus on high-tech, complex, hospital- and specialty-based care that is very costly, our population is generally not healthy when compared to many other countries.
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