As a Clevelander, I was raised a fiercely loyal sports fan – often times witnessing, shall we say, subpar outcomes. When LeBron James returned to Cleveland, he ignited a sense of hope in Clevelanders. To maximize the full potential that came with James, organizational change and sacrifice was in order. Kevin Love, a prolific power forward who led his previous team in scoring and rebounding, was acquired and asked to assume a new role as a third option and a facilitator while still remaining deadly from the corner. J.R. Smith, a singularly focused scorer, became a two-way player able to defend opposing guards while embracing a more specialized shooting role. Through strategic adjustments, acquisitions, and difficult leadership changes, the Cavs successfully transformed their culture and team around James, and brought the people of Cleveland a much-appreciated 2016 championship organization.
The Cavs organization’s winning approach may serve as a lesson for integrating health systems through collaboration, partnerships, and acquisitions. Organizations are evaluating strategies that best to improve their core business, expand the scope of what they can offer a patient, and better manage that patient’s experience at a lower cost. Health plans and providers can continue to seek opportunities to integrate in ways that allow them to collaborate, optimize strengths, and eliminate duplication.
Ultimately, a large success factor hinges on their ability to clearly define their changing operating model, organizational structure, and talent strategy in support of a more optimized care management offering (including utilization management, care coordination, and disease management). Care Management’s focus on driving customer / patient experience represents a tremendous opportunity to integrate. Improving the patient experience through integration may also allow health plans and providers to improve revenue growth, with a recent Deloitte analysis finding that a 10 percent increase in patients rating hospitals as “excellent” can increase margin by 1.5 percent.
Care management services to be considered for potential integration:
• Community resources
• Data management and analytics
• Digital and telehealth offerings
• Disease management
• Embedded care management
• Medication reconciliation/adherence
• Physician engagement
• Patient engagement
• Post-acute care management
• Wellness and prevention
Strategic partnerships – like Humana’s bundled payment partnerships with providers, Aetna’s joint ventures with providers, or even the creation of a health plan by the provider itself – demonstrate the number of ways in which plans and providers can integrate. Humana is working to better integrate its orthopedic practices with its population health data and analytics function, delivering information that can help to better coordinate care and reduce readmission and complication rates. Kaiser made strategic choices about how their three unique organizations could be realigned to a new operating model to help achieve greater executive alignment and improve communication across functions.
In all these options, incentive alignment is critical and those providers participating in greater amounts of risk-sharing typically demonstrate intensified care management integration when other entities involved also participate in the risk-sharing agreements. While a number of factors must be taken into consideration when choosing the right model, including geography, maturity of care management services, existing relationships with plans or providers, etc., the three types of operating model structures that we find to be particularly applicable include:
Plans and providers may successfully navigate the shift toward integration by pursuing a few key next steps:
• Evaluating the key components of the care management lifecycle to better identify opportunities to improve through harmonization/centralization of capabilities versus through greater coordination of key handoffs, keeping in mind that opportunities may vary at different stages in the patient lifecycle
• Mapping necessary capabilities to jobs required and highlighting where critical shifts in behavior / culture / approach will be needed
• Developing optimized organizational structures and identifying appropriate leadership roles
• Refining stratification methodologies to better understand the populations and volumes to focus appropriate level of resources
These next steps are all part of a difficult journey. But getting to the winning organization solution doesn’t happen by accident. As with the Cavs, it requires strategic decision making, thoughtful trade-offs that support the end-goal, and smart alignment of the key players involved.