About Dr. Sachs
Dr. Jeffrey Sachs has been a pioneer in health care reform and system transformation for over three decades. He was one of the key architects of New York’s Medicaid Redesign Team process and the Global Medicaid Cap. He provided key guidance to the State of California in the development of its 1115 Medicaid waiver in 2010, which created the first DSRIP program in the United States and provided for $10 billion in new federal funding in California. Dr. Sachs founded Sachs Policy Group to advise organizations across the health care industry on how to adapt and thrive in a changing policy and market landscape. He has advised hospitals, health systems, health plans, behavioral health organizations, technology companies, long term care organizations, unions and others.
We were fortunate enough to sit down recently with Dr. Jeff Sachs, founder and head of the Sachs Policy Group, to explore some of his views on the evolution of value-based care and the central role of referral management in that evolution. Here are some excerpts from that conversation:
Q: For quite some time, you have been a strong advocate for switching to value-based, versus fee-based, healthcare delivery models in order to improve overall health outcomes. What are the key drivers that formed your view?
You really do get what you pay for, and I saw going back to the 1980s that if you pay for volume and complexity, but not quality or outcomes, then the system is going to deliver volume and complexity but do a much less consistent job at delivering better quality and outcomes. That observation has only been reinforced over the years, and so has my belief that the delivery system needs transformative change in order to orient itself to delivering better health with the needs of the patient at the center. It’s hard to do, because health care does not naturally lend itself to being consumer-driven in the way that media or technology are. Technology itself is actually an essential mechanism in changing the delivery system to make it more consumer-centric and focused on value. I think the pressures and possibilities created by new technologies to coordinate care, share information and guide better work flows are even stronger drivers of change than government policy at this point. Especially now, with policy so much in flux with the recent election, and a Republican administration likely to increasingly turn to the market for solutions to problems.
Q: You have said that referral management is one of the linchpins of successfully implementing a value-based care scheme. Can you elaborate why this is so?
Three important obstacles that tie into the referral process hold us back from achieving true value-based care: 1) the referring provider has little insight into the optimal specialists to whom to refer a specific patient, from a value-based point of view; 2) the referring provider and the specialist have little control over how each other delivers the care to each specific patient, given the difficulty and inefficiency of coordinating care across organizations and platforms, and patient availability; and 3) all providers lack sufficient visibility into “how it’s going right now” in order to modify their approach and the choices they make each day. These obstacles can be overcome with a comprehensive referral management capability that is fed by quality-of-outcomes data, incorporates evidence-based guidelines where appropriate in the early stages of the transition between providers (aka a referral), and which simplifies care coordination and data transparency. Such systems exist already, they just haven’t yet been embraced and deployed for what they could do – but the potential is massive.
Q: Many people have said that better referral management is achievable now, due to the emergence of recent technological innovations. What improvements are you seeing networks deploy and how is that affecting the quality of care?
There are several firms offering referral management capabilities that go beyond the clinical data sharing schemes currently being pushed by all the EMR vendors. The entire decision as to who to refer to, when the patient and their primary doctor arrive at that decision, and how to coordinate the care as it’s being given by both PCPs and specialists is not even part of the remit of an EMR system. Once that decision is made, and the clinical data associated with the patient being referred is ready to be transferred, there are any number of ways to accomplish that task – including HIEs, Direct Trust, or real-time exchange through one of the cloud-based referral platforms like ReferWell&tm;.
What we’re seeing is that some networks are recognizing the distinction between referral management on the one hand, and clinical data sharing on the other. By separating those processes and focusing first on managing the referral decision-making tasks more efficiently and effectively, these networks are finding that they can make a significant impact on the cost and quality of care resulting from referrals. With those improvements in place – including the ability to make scheduled appointment times available to the PCP and their patient at the point of care, sharing insurance coverage information so the patient can avoid showing up at a specialist who doesn’t take their insurance, etc. -- they can then decide exactly how best to make sure the patient’s clinical information arrives from the primary doctor to the specialist. Here again, we’re seeing some innovations in allowing real-time communications between providers on different EMRs that operate much like a Facebook wall, so it’s intuitive and easy to use, but HIPAA-secure and limited to only that patient/doctor combination. All of these exciting innovations are moving the quality of care ahead in ways big and small, from improving patients’ experience and rate of compliance to facilitating comprehensive and continuous coordination of care between otherwise unconnected doctors, clinics, imaging centers, physical/occupation/behavioral therapists, and home care providers.
Q: You said recently at the CHCANYS conference that digital health technology would accelerate the movement toward comprehensive care coordination and value-based care delivery. Are there any advances in particular that you find promising?
The next generation of telehealth technologies is very promising and I think moving in the right direction to be fully and thoughtfully integrated with the delivery of care. For example, one solution available for nursing facilities provides on-call physician services at the bedside via video with specially designed devices that let the remote physician view and hear the patient’s symptoms in some ways even better than a typical physician at the bedside. Nurses who need physician support after hours can get it, which provides relief to them and prevents unnecessary hospital admissions. Portable technology is also helping to transform the delivery of care in one of the most neglected areas: home care. And of course, technology is improving the ability to keep care within a coordinated, value-aligned network through referrals for medication, specialist care, post-acute care and other major cost-driving areas.
Q: What are the major obstacles to the adoption of value-based care in New York, and in the country at large?
The inertial force provided by culture is not to be underestimated! It’s hard to change mindsets that have built up over decades and been enshrined in institutions, work flows and attitudes. But beyond that, the period of transition between FFS and value-based care (particularly the more meaningful models that include financial risk for underperformance) is hard because every provider making the transition has a foot in two canoes that are pulling in opposite directions. It’s not an easy place to stand, and we don’t get anywhere by just standing still, so I’m always looking for ways that we can responsibly accelerate the transition to value to remove conflicting incentives, while making sure that providers are positioned to succeed in the new world. This successful positioning can mean many things: culture change of course, but also forging new partnerships and ways of using information across organizations.
Q: Thank you so much for your time, it has been a pleasure speaking with you. Thank you, it was great talking with you too. And we barely even mentioned the election!