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In the United States, we are spending more on healthcare and deriving far less value than most other countries. This trend is unsustainable at best and could lead to serious consequences in the future if it is not controlled soon. In today's fee-for-service-based reimbursement model, health plans and providers have long viewed each other as adversaries. It is an inherent flaw in the system: Insurance plans that need to keep premium costs low to win bids from employers are directly at odds with provider organizations motivated to set fee schedules high enough to cover salaries and overhead.
Compounding this friction is the fact that the current national healthcare spending trajectory-$2.6 trillion in 2010-affects our entire economy. Fragmented care is a leading reason that costs are so high. As well, it increases risks to patient safety. More than 50 percent of Medicare beneficiaries, for instance, have five or more chronic conditions such as diabetes, arthritis, hypertension, or kidney disease. Often, these patients are cared for by multiple physicians at various facilities. The resulting uncoordinated treatment can lead to redundant care, superfluous testing, increased exposure to medical error and unnecessary costs.
 It is clear that the status quo cannot continue if the healthcare industry is to move forward into a new era of patient-centered care and outcome-based reimbursement. Providers and health plans must bury the hatchet and learn to pull together toward the common good of patients.
Current legislation and newly enacted healthcare reform measures encourage this kind of cooperation. Most have been designed in an effort to shift focus away from the provision of acute care and toward more preventive care and outcome-based reimbursement. Emerging data from both commercial and governmental payers reinforces the efficacy of this approach. It suggests that information shared between health plans and providers can lead to improved disease management and better clinical outcomes over time.
The patient-centered medical home (PCMH) is one collaborative care model gaining traction in the medical community as an antidote to fragmented care. A recent Medical Group Management Association (MGMA) survey reveals that 20 percent of provider respondents already are affiliated with a PCMH and another 70 percent are receptive to the idea, especially with financial incentives to participate. The health plan community also is quickly moving to PCMH. However, for collaborative models such as PCMH to achieve desired cost and clinical results, communication between health plans and providers must be cultivated as never before.
The Rise of Real-Time Healthcare Communications
Health information technology (HIT) plays a pivotal role in enabling providers, health plans, patients, and others within the healthcare continuum to share information. Yet, it is important to recognize both the benefits and the limitations of different IT components. Electronic health records (EHRs), for example, are terrific tools to help promote safer and more efficient care for individuals at the encounter level. Most, however, are not equipped to adequately support population management. Individual EHR systems may be lacking in decision-support and registry tools and, thus, are of limited value for sharing care plans and supporting a team of providers working together.
In much the same way, collaborative care models such as PCMH will work best if all parties recognize and utilize the strengths that each brings to the table. Merging clinical information from the provider side with financial and administrative data from the health plan side, for instance, permits everyone access to a more complete picture of patient care. This can be accomplished though a single, secure, real-time source of patient-related information from multiple health plans.
One essential aspect to achieve the desired outcomes is workflow integration. In order to effectively coordinate care - and to avoid confusion at the provider level - data must be presented in a standardized manner by all health plans. In addition, providers need to be able to access data across a variety of technology platforms, including portals, smart phones, and tablets.
Once all stakeholders have equal access to each other's data, the industry can begin to focus collectively on ways to improve care quality while reducing costs. Consider the role of health plans and providers in promoting preventive care, for example. The vast majority of health plans currently has direct outreach programs in place to support their prevention efforts - communication driven by the desire to both increase patient health and decrease illness-related costs. But is that the most efficient way to reach these goals?
When this information comes from a provider at the point of care - as opposed to a health plan - it carries far more credibility with patients. Moreover, the ability to integrate health plan claims-derived gaps in care with provider EHR, practice management, and scheduling systems results in a far more timely and accurate approach to communicate with patients concerning preventive and chronic care. Furthermore, by acknowledging that physicians are the most effective channel for this communication, health plans can help strengthen the provider/patient relationship, increase the quality of patient care, and save administrative costs, as well.
Today, healthcare communication networks are starting to make the vision of collaborative care a reality. Early pilot results on PCMH confirm that this model saves money and improves clinical quality. Rather than fostering traditional adversarial relationships, services exist that can link together hundreds of thousands of healthcare professionals, leading insurance plans, and other stakeholders on a single platform. Clinical and financial transparency then spans across the healthcare continuum. By bringing health plans and providers together through real-time data exchange, our industry can coordinate care and align reimbursement with patient outcomes. From there, it is a much shorter step to the end goal of reducing costs while improving care quality. We have the opportunity to rapidly  achieve superior clinical outcomes and better health of populations - and to bend the cost curve. The time to act is now.
S. Michael Ross is chief medical officer of NaviNet, a real-time healthcare communications network.
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